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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002812
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:20:48 PM

Document Has Been Signed on 10/24/2024 12:20 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BLESSED HOMECARE 2 ROSEVILLEFACILITY NUMBER:
315002812
ADMINISTRATOR/
DIRECTOR:
ARGANA, FERDINANDFACILITY TYPE:
740
ADDRESS:4100 SHORTHORN WAYTELEPHONE:
(209) 834-4040
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
10/24/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Leriza ArambuloTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Cassandra Mikkelson conducted a follow up visit regarding deficiencies cited during the annual inspection on 10/02/2024.

LPA requested a copy of the updated certificate of liability insurance. LPA was provided with a copy of a proposed liability insurance which is in process. Facility will send a copy of certificate of liability insurance to LPA once renewed.

LPA observed the RCFE poster had not been displayed in a common area in facility. LPA requested that regulation sized (20' by 26') RCFE poster be displayed at facility.

LPA reviewed six (6) resident files. LPA observed that physician reports for R1 and R2 had been filed in the appropriate resident files. LPA observed that needs and services plan for R1 and R2 were partially completed and not signed in files. LPA requested that needs and services plans for R1 and R2 be completed and signed. Deficiency 87458(a), is has been cleared.

LPA requested a copy of the emergency drill log and disaster plan. LPA observed emergency drill log and disaster plan were current. LPA also asked for the infection control plan. Facility will email infection control plan to LPA. Deficiencies 1569.695(c) and 1569.695(d) have been cleared.

The following was observed but not cited during this visit: there was an easy chair blocking one of the doors between the hallway to the resident rooms and the common area preventing it from closing. The doors are there per the fire department. The chair was moved during the visit and staff were advised to not block the door. It was not cited because the easy chair was easily moved out of the way.
No deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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