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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880726
Report Date: 10/13/2022
Date Signed: 10/13/2022 04:24:00 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/13/2022 04:24 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
, 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:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH: Ashish BhambhaniTIME COMPLETED:
04:30 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. This facility has not admitted their first resident since licensure. LPA met with Ashish Bhambhani and has reminded them to contact this agency once a resident is retained. LPA conducted a brief tour of the facility and discussed the facility's infection control measures.

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: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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