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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002812
Report Date: 11/06/2024
Date Signed: 11/06/2024 04:44:07 PM

Document Has Been Signed on 11/06/2024 04:44 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:
11/06/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:10 PM
MET WITH:Christinet CapiliTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
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LPA Hiratsuka conducted this unannounced plan of correction visit.

This is a follow-up to deficiencies issued on 10/24/2024, and not corrected until Sunday, November 3, 2024. Civil penalties were issued on 10/30/2024 and accrued at $100.00 per deficiency per day and the civil penalties will stop on November 3, 2024.
The following deficiencies have now been cleared:
Health and Safety Code 1569.312(3) Basic Services-
Title 22 Regulations
87307(d)(6)
87465(e)

The following deficiencies were due on October 31, 2024. LPA spoke to Caregiver Leriza Arambulo, on the phone today and Caregiver stated she didn't see the remaining deficiencies. She stated she thought there were only the ones above. LPA is leaving a copy of all reports that were issued on 10/24/2024.

A reminder that annual fees are due on 11/12/2024. Licensee is to submit a staff schedule or LIC 500 to Community Care Licensing Division

The person appointed by Licensee to be administrator Maria Clardy, is not associated to this facility. Licensee shall submit the transfer request to Community Care Licensing Division prior to Ms. Clardy working at this facility.
No deficiencies cited
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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