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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002812
Report Date: 10/30/2024
Date Signed: 10/30/2024 04:07:46 PM

Document Has Been Signed on 10/30/2024 04:07 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
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:
10/30/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Baby Quintero, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to complete a POC visit in concerns to the annual inspection on 10/02/24. LPA met with licensee Baby Quintero during today's inspection.

During today's inspection LPA reviewed POC's that were due by 10/18/24. LPA assessed civil penalties for the following deficiencies:
  1. Post the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475). Although licensee posted the poster, it was not the correct size 20” x 26”.
  2. Complete a needs and service plan for R1 and R2. Licensee submitted an incomplete needs and service plan, and only completed and sent 1 page.
  3. Complete a statement of understanding and send the plan into LPA. Licensee did not send a statement of understanding for regulation 87506.

Licensee sent in a infection control plan on 10/17/24, however licensee did not complete the plan properly. Licensee agrees to complete the infection control plan on form LIC9282 and send a copy into LPA by 11/4/24.

Licensee agrees to complete POC's by 11/4/24 and send into LPA.

Civil penalties assessed. Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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