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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601459
Report Date: 06/27/2025
Date Signed: 06/27/2025 01:18:06 PM

Document Has Been Signed on 06/27/2025 01:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BLISSFUL CARE HOME LLC.FACILITY NUMBER:
015601459
ADMINISTRATOR/
DIRECTOR:		BUCTUAN-ROTOR, MARLYN & MAFACILITY TYPE:
740
ADDRESS:1381 VIA LA PALOMATELEPHONE:
(510) 278-0222
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY: 6CENSUS: 4DATE:
06/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 06/27/2025 at 9:00 AM, Licensing Program Analyst (LPA) Y. Brown and Licensing Program Manager (LPM) Harpreet Humpal conducted an unannounced annual 1-year required inspection. LPA met with Administrator Marlyn Rotor and explained the purpose of the visit.

The administrator currently holds a certificate (#7002539740) that expires on 12/16/2025. The facility’s fire clearance was approved for six (6) residents, six (6) may be non-ambulatory. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) bedrooms and two (2) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 73 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients.

Hot water temperature in the facilities kitchen was measured at 123.1 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents. Smoke detectors and carbon monoxide combination were in operating condition during visit. Fire extinguisher was last purchased on 7/26/2025. First aid kit was observed to be complete. LPA reviewed four (4) staff and four (4) client records. LPA reviewed a sample of medication.

Continued on LIC809C.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/27/2025 01:18 PM - It Cannot Be Edited


Created By: Yasamin Brown On 06/27/2025 at 11:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BLISSFUL CARE HOME LLC.
FACILITY NUMBER: 015601459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that out of the 4 staff members, none of the staff members on duty had proof of CPR training in which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/07/2025
Plan of Correction
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The Administrator agrees to schedule at least one staff member to recieve CPR training and submit documentation of scheduled training to CCLD by POC date. Administrator agreed to also send the completion of the training on 07/11/2025.
Type A
Section Cited
CCR
87411(c)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 0 out of 4 staff members did not have first aid certification on file which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/07/2025
Plan of Correction
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The Administrator agrees to schedule all staff members to recieve first aid training and submit documentation of scheduled training to CCLD by POC date. Administrator agreed to also send the completion of the training on 07/11/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/27/2025 01:18 PM - It Cannot Be Edited


Created By: Yasamin Brown On 06/27/2025 at 11:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BLISSFUL CARE HOME LLC.
FACILITY NUMBER: 015601459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that S1, S2, S3, and S4 had missing 20 hr annual training which poses a potential health and safety risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Administrator agreed to submit documentation of completed 20 hr annual training to CCLD by POC date.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that R1 and R2 had missing Appraisal needs and service plans which poses a potential health and safety risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Administrator agreed to submit documentation of completed Appraisal Needs and Services plan for R1 and R2 to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 06/27/2025 01:18 PM - It Cannot Be Edited


Created By: Yasamin Brown On 06/27/2025 at 12:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BLISSFUL CARE HOME LLC.
FACILITY NUMBER: 015601459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)(3)


This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on file review, the licensee did not comply with the section cited above in that the facility did not have a current fire drill since the last drill was conducted in July 2024 which poses a potential health and safety rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Administrator has agreed to conduct emergency disaster fire drills quarterly and will send a copy of the most recent drill to CCLD by POC date. Administrator has agreed to conduct a fire drill in the facility by 7/11/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BLISSFUL CARE HOME LLC.
FACILITY NUMBER: 015601459
VISIT DATE: 06/27/2025
NARRATIVE
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(Continued from LIC809...)

The following forms will be updated and submitted to CCLD by 7/7/2025:

  • LIC610D: Emergency disaster plan (last page)
  • LIC500: (Personnel Record)
  • LIC622A: Medication Administration Record (MAR)
  • LIC9283: Infection Control Plan
  • Updated Floor Plan: Documenting that the outdoor "restroom/storage" will be changed to a staff room.

The following deficiencies were observed:
  • At 9:45 am, LPA observed R1 had a half bed rail but no written physicians order.
  • At 10 am, LPA observed missing CPR training from 0/4 staff members.
  • At 10:05 am, LPA observed missing 20 hr training from 0/4 staff members.
  • At 10:15 am, LPA observed R1 and R2 had missing Appraisal needs and services plan.
  • At 10:20 am, LPA observed that there wasn't an updated quarterly fire drill conducted.

A technical violation was issued during the visit.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.


Exit interview conducted. A copy of the appeal rights and this report provided.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 06/27/2025 01:18 PM - It Cannot Be Edited


Created By: Yasamin Brown On 06/27/2025 at 12:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BLISSFUL CARE HOME LLC.
FACILITY NUMBER: 015601459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)


This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation and record review, the licensee did not comply with the section cited above in that R1 had a half rail bed but during record review, R1 did not have an approved doctor's order which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Administrator agreed to obtain a written order from a physician indicating the need for the postural support for R1 and proof of documentation will be submitted to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
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