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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006367
Report Date: 01/09/2025
Date Signed: 01/09/2025 04:21:28 PM

Document Has Been Signed on 01/09/2025 04:21 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BLISS CARE HOMEFACILITY NUMBER:
306006367
ADMINISTRATOR/
DIRECTOR:		NANDWANI, NIDHIFACILITY TYPE:
740
ADDRESS:2609 EAST SANTA YSABEL AVENUETELEPHONE:
(909) 964-6720
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 6CENSUS: 4DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Deisy Sakul, Nidhi NandwaniTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad, Hanna Gough, and Nancy Guillen for the purpose of conducting a Required – 1 Year Inspection. LPAs met with Staff #1 (S1) Deisy Sakul and discussed the purpose of the inspection. Administrator (AD) Nidhi Nandwani arrived during the inspection.

LPAs reviewed Infection Control requirements. At about 10:30AM, LPAs and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 6-bedroom, 3-bathroom, one-story house with a detached garage that is used for storage. There is a back yard with a patio cover for the residents. LPAs and AD observed 1 staff and 3 residents present at the facility. Resident Bedrooms: the 5 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPAs inspected the one staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 114.6 and 114.7 degrees F in the 2 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the medication cabinet, after corrections. Toxins: observed locked in the garage, after corrections. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 11:30AM, LPAs reviewed 4 resident files and 3 staff files, interviewed 2 residents and 2 staff, and inspected medications for 4 residents. Facility does not handle resident money.

CONTINUED.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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 6
Document Has Been Signed on 01/09/2025 04:21 PM - It Cannot Be Edited


Created By: Sean Haddad On 01/09/2025 at 03:55 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BLISS CARE HOME
FACILITY NUMBER: 306006367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, a staff has been living in the accessory dwelling unit (ADU) behind the garage for almost a month, but the ADU has not been fire cleared as a bedroom, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.
POC Due Date: 01/10/2025
Plan of Correction
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Licensee stated they do not want to use the ADU as a bedroom and removed the beds during the inspection and LPAs confirmed. POC CLEARED.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the facility did not ensure knifes, scissors, pesticides, dishwasher detergent, and other dangerous items were inaccessible to residents whose assessments do not allow for handling of such items, which poses an immediate safety risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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During the inspection, Licensee removed these items and LPAs confirmed. Licensee to conduct training and submit proof to LPA by January 16, 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/09/2025 04:21 PM - It Cannot Be Edited


Created By: Sean Haddad On 01/09/2025 at 03:55 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BLISS CARE HOME
FACILITY NUMBER: 306006367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Guardian documents and interviews, the licensee did not ensure staff John Ferdinand Senewe observed by LPAs at the facility, who lives at the facility and has worked here for almost a month, was background cleared as their status is pending in Guardian, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.
POC Due Date: 01/10/2025
Plan of Correction
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During the inspection, the staff stated this was their last day and they were moving out. Licensee removed this staff from the facility and LPAs confirmed. POC CLEARED.
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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/09/2025 04:21 PM - It Cannot Be Edited


Created By: Sean Haddad On 01/09/2025 at 03:55 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BLISS CARE HOME
FACILITY NUMBER: 306006367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025

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 documents, the licensee did not maintain documentation of required training for 2 out of 2 staff, which poses a potential safety risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Licensee stated they will train all staff as required and submit proof to LPA by POC due date.
Type B
Section Cited
CCR
87465(a)(1)
Incidental Medical and Dental Care Services
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and admission, the licensee has been administering supplements but does not have doctor's orders for these supplements, which poses a potential health risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Licensee stated they will obtain doctor's orders for all supplements given to residents and submit proof to LPA by POC due 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/09/2025 04:21 PM - It Cannot Be Edited


Created By: Sean Haddad On 01/09/2025 at 03:55 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BLISS CARE HOME
FACILITY NUMBER: 306006367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents and admission, the facility did not conduct emergency disaster drills quarterly in 2024 as they only conducted 3 drills in 2024, which poses a potential safety risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Licensee stated they will conduct a fire drill, submit proof to LPA by POC due date, and will conduct emergency disaster drills quarterly moving forward.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BLISS CARE HOME
FACILITY NUMBER: 306006367
VISIT DATE: 01/09/2025
NARRATIVE
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During the inspection, LPAs and AD observed the following: based on observation and interview, a staff has been living in the accessory dwelling unit (ADU) behind the garage for almost a month, but the ADU has not been fire cleared as a bedroom; based on observation, the facility did not ensure knifes, scissors, pesticides, dishwasher detergent, and other dangerous items were inaccessible to residents whose assessments do not allow for handling of such items; based on Guardian documents and interviews, the licensee did not ensure staff John Ferdinand Senewe observed by LPAs at the facility, who lives at the facility and has worked here for almost a month, was background cleared as their status is pending in Guardian; based on documents, the licensee did not maintain documentation of required training for 2 out of 2 staff; based on observations and admission, the licensee has been administering supplements but does not have doctor's orders for these supplements; and based on documents and admission, the facility did not conduct emergency disaster drills quarterly in 2024 as they only conducted 3 drills in 2024.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM, LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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