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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002812
Report Date: 03/11/2025
Date Signed: 03/11/2025 10:24:49 AM

Document Has Been Signed on 03/11/2025 10:24 AM - 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: 5DATE:
03/11/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Baby Quintero, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cassandra Mikkelson and Cheyenne Ratajczak arrived to the facility to conduct a case management visit. LPAs met with Licensee and explained the purpose of the visit.

LPAs conducted a file review of five (5) resident files, toured the facility and conducted interviews.

As a result of this visit, deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D pages.

Exit interview was conducted with Licensee. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/11/2025 10:24 AM - It Cannot Be Edited


Created By: Cassandra Mikkelson On 03/11/2025 at 10:04 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: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2025
Section Cited
CCR
87458(c)(1)(a)

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87458 Medical Assessment (c) The medical assessment shall include...: (1) A physical examination...indicating the licensed medical professional's diagnosis... and results of an examination... (A) Communicable tuberculosis. This poses a potential health and safety risk to the residents in care.
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Licensee will ensure that R1 receives Tuberculosis test by POC due date. Licensee will ensure that all new residents have a tuberculosis test prior to move in.
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This was not met as evidenced by: Based on records reviewed and interviews conducted, R1 did not have a Tuberculosis test completed prior to moving into facility.
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Type B
04/01/2025
Section Cited
CCR87456(a)(2)(4)

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87456 Evaluation of Suitability for Admission (a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall... (2)Perform a pre-admission appraisal. (4) Execute the admissions agreement. This poses a potential health and safety risk to residents in care.
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Licensee will ensure that R2 has signed admission agreement and apprasal completed by POC due date. Licensee will ensure that all new residents have an admission agreement and pre- placement appraisal completed prior to move in.
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This was not met as evidenced by: Based on records reviewed and interviews conducted, R2 did not have an admission agreement or pre-admission appraisal completed prior to moving in.
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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:Laura Munoz
LICENSING EVALUATOR NAME:Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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