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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880726
Report Date: 09/29/2021
Date Signed: 10/22/2021 04:37:10 PM

Document Has Been Signed on 10/22/2021 04:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BLISS HOMESFACILITY NUMBER:
331880726
ADMINISTRATOR:BHAMBHANI, BHAVNAFACILITY TYPE:
740
ADDRESS:6149 COOPERS HAWK DRIVETELEPHONE:
(714) 224-6763
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY: 6CENSUS: 0DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:ASHISH BHAMBHANITIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Amy Goldenberg made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. This facility is currently is not retaining any residents and have not made their first admission yet post licensure. LPA met with Ashish Bhambhani.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. LPA advised the facility representative of the departments availability off PPE and procedure to acquire supplies. LPA discussed sign in and screening procedures with the Ashish. LPA advised the facility representative to contact LPA once a resident is accepted into the facility.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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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