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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 12:23:15 PM

Document Has Been Signed on 10/24/2024 12:23 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: DATE:
10/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Leriza "Riza" ArambuloTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Hiratsuka and Mikkelson, conducted this unannounced case management visit in response to investigating Complaint 59-AS-20241022104408.

The following observations were cited:

-There are no audio alerts on the exits to the outside. Title 22 Regulations require audio alerts on all exit doors when exiting poses a hazard to residents. There are two residents who attempt to leave or have left the facility unnoticed and the audio alerts were turned off. Licensee stated the audio alert batteries die quickly so she put two chairs in front of the door and a wood rod in the sliding glass door (cited on complaint visit)

-A review of Resident (R1) needs and services plan it does not state the resident wanders outside and has left the facility a couple of times unnoticed by staff. There is no plan to address the resident attempting to leave the facility.

-A Review of Resident (R2) file, the needs and services plan has White-Out on it with R2's name handwritten on it but the plan itself mentions another person.

-A review of R2's file shows R2 does not have a pre-placement appraisal. Title 22 requires a pre-placement appraisal and annual appraisal.

-Licensee did not report R1 leaving the facility unnoticed by staff within 24 hours or by next business day by fax or phone call as required by Title 22 regulations. The resident leaving the facility unassisted meets the 24 hour notice because it threatened the health and welfare of the resident. The resident was found unharmed.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ROSEVILLE
FACILITY NUMBER: 315002812
VISIT DATE: 10/24/2024
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LPA Hiratsuka informed License Baby Quintero during a phone call that a meeting between Community Care Licensing Division and her shall be scheduled to address all the issues cited on the complaint and issues cited on this report.


Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.
Exit interview conducted. A copy of the report has been issued.Failure to correct the deficiencies may result in Civil penalties being assessed. Appeal Rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
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
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/24/2024 12:23 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 10/24/2024 at 11:20 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER: 315002812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2024
Section Cited
CCR
87705(j)

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Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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By 10/25/2024, Licensee shall come up with a written plan to address the audio alerts on the doors since there are two residents who attempt to leave out of the front door and one made it out the back door and side gate unnoticed by staff.
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This was not met as evidenced by: LPAs observed the audio alerts were not working and Licensee stated the batteries die quickly so she put chairs to block the entrance so staff can hear the chairs move.
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Type A
10/25/2024
Section Cited
CCR87463(a)

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Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition...
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By 10/25/2024, the licensee shall update the appraisals to address the current needs of the residents. Licensee shall come up with a written plan on how she shall ensure the appraisals done on each resident is complete and addresses any and all needs of the residents and submit that plan to
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This was not met as evidenced by the appraisal has not been updated to address the resident wandering and leaving the facility unoticed by staff
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Community Care Licensing Division.
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:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2024 12:23 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 10/24/2024 at 11:33 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER: 315002812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
87457(a)

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Pre-Admission Appraisal - General. Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions
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By 10/31/2024, Licensee shall come up with a written plan of correction on how she shall ensure pre-admission appraisals are completed and with the correct resident name is on it.
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This was not met as evidenced by, a review of R2's file there was not a pre-admission appraisal completed. There was one that had White-Out on it with R2's name written on top but someone else's name on the form.
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Type B
10/31/2024
Section Cited
CCR87211(a)(2)

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Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health
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By 10/31/2024, the licensee shall come up with a written plan on how she shall ensure she shall meet the reporting requirements of Title 22 Regulations.
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of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency.
Licensee did not report the resident who left the facility unassisted to Community Care Licensing Division as of today's visit.
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
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