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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 04:00:59 PM

Document Has Been Signed on 10/30/2024 04:00 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:
10/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Baby O QuinteroTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensed Program Analysts (LPAs) Cassandra Mikkelson and Kerry Hiratsuka arrived unannounced to conduct a Case Management following deficiencies cited.

During annual visit on 10/02/2024 conducted by LPA Bethany Mirlohi, the following deficiencies were cited. 87506 Resident Records (a)- facility did not meet regulations for resident files, ensuring that all resident files are complete and up to date.
87457(c)- Resident's needs and service plans were absent in resident files.
87458(a)- Residents physicians' report were absent in resident files.
1569.69(a)(2)- Administrator did not ensure that all employees, new and existing, meet the appropriate training requirements per Title 22 regulations.

During complaint visit on 10/24/2024 conducted by LPA Mikkelson and Hiratsuka, the following deficiencies were cited.
87203- Fire safety- facility had chairs blocking the front door and a wooden dowel blocking the glass sliding door.
1569.312(e)- Licensee not ensure the safety of the resident by a resident leaving the facility through the side gate unnoticed by staff. This is an immedate health and safety risk to residents
87465(g)- Licensee did not ensure the safety of the resident because a resident left the facility unassisted and the Licensee did not call for emergency services for at least 30 minutes.

*Continued on LIC 809-C
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
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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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: 10/30/2024
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During Case Management visit on 10/24/2024 conducted by LPA Mikkelson and Hiratsuka, the following deficiencies were cited.
87705(j)- 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.
87463(a)- The appraisal has not been updated to address the resident wandering and leaving the facility unoticed by staff.
87211(a)(2)- Facility did not meeting reporting requirements according to Title 22 regulations when incidents occur.

It was learned today that Licensee did not report to Licensing when a resident left the facility unnoticed.

There is also not a current administrator for facility. The Department was not notified with a change of administrator.

Based on deficiencies during 10/02/2024 annual visit and complaint visit on 10/24/2024 and case management visit conducted on 10/24/2024, it shows that there is no qualified administrator operating the facility.

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: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
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
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/30/2024 04:00 PM - It Cannot Be Edited


Created By: Cassandra Mikkelson On 10/30/2024 at 03:29 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER: 315002812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2024
Section Cited
CCR
87405(a)

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87405 Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...
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By 11/06/2024, the Licensee shall appoint a qualified administrator and submit a written plan on how she shall show that there will always be a qualified administrator working.
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This was not met as evidenced by: Based on interview, it was learned that there is no current administrator for this facility. This poses a possible risk to the residents in care.
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Type B
11/06/2024
Section Cited
CCR87211(g)(1)

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The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following:
Name and residence and mailing addresses of the new administrator.
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By 11/06/2024, the Licensee shall appoint a qualified administrator and submit a written plan on how she shall show that there will always be a qualified administrator working. Licensee will also submit written notification to the Department of change in administrator.
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This was not met as evidenced by: Based on interview, it was learned that there is no current administrator for this facility and the Department was not notified. This poses a possible risk to the residents in care
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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:Anthony Perez
LICENSING EVALUATOR NAME:Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/30/2024 04:00 PM - It Cannot Be Edited


Created By: Cassandra Mikkelson On 10/30/2024 at 03:39 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER: 315002812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2024
Section Cited
CCR
87211(a)(1)

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87211: Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence
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By 11/06/2024, Licensee will submit a written plan of how facility will ensure that all incidents are reported to the Department and all relavant parties.
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This was not met as evidenced by: Based on interview, it was learned that facility did not report resident leaving facility unnoticed. This poses a possible risk to residents in care.
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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:Anthony Perez
LICENSING EVALUATOR NAME:Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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