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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881468
Report Date: 01/31/2024
Date Signed: 01/31/2024 11:49:13 AM

Document Has Been Signed on 01/31/2024 11:49 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BLAS HOMES, LLCFACILITY NUMBER:
331881468
ADMINISTRATOR:BLAS, DANIELFACILITY TYPE:
740
ADDRESS:11964 WELBY PLACETELEPHONE:
(909) 636-8288
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 0DATE:
01/31/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:DANIEL BLASTIME COMPLETED:
11:55 AM
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On 1/31/2024, Licensing Program Analyst (LPA), Chinwe Nwogene conducted an announced pre-licensing inspection at the facility. LPA Nwogene met with Applicant, Daniel Blas and toured the facility.

Application: The application is for a Residential Care Facility for the Elderly. The fire clearance has been granted for six (6) ambulatory residents.

Buildings and Grounds: The home is composed of Livingroom, kitchen, and dining room combination, three (3) client bedrooms, one (1) resident restroom, master bedroom with master bathroom (non-resident room), a garage, and backyard. The interior/exterior walkways of the home were observed to be clutter free with no obstructions. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Daniel, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair and privacy is available. The dining and living room areas/furniture are clutter free and in good condition. Bathrooms were observed to be cleaned. The hot water was tested and measured at 126 degrees Fahrenheit which is above regulatory limits. Outdoor areas had sufficient room for activities. A washing machine and dryer are available and in working order. Central heating and air conditioning system installed with a central panel located in hallway to control entire house.

Storage and Supplies: Medications will be stored in a locked closet, inaccessible to any unauthorized individuals. Secured areas are available for facility files and resident files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in a closet, inaccessible to clients. A Fire extinguisher was available and fully charged.

CONTINUE ON LIC809-C

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
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 15
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BLAS HOMES, LLC
FACILITY NUMBER: 331881468
VISIT DATE: 01/31/2024
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CONTINUED FROM LIC809

Activities: Inside and outside, there are areas for residents to use for their leisure. The backyard is in good condition with a covered patio to provide shade over the outside table and chairs.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a locked closet , available only to authorized individuals. Trash cans have tight-fitting lids. Dishwasher will be used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean.

Missing Items:

  • Bedroom furniture (chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers)
  • Night Lights
  • Towels and Linens
  • Grab bars and non-skid mat
  • Hot water temperature (105 -120)
  • Exit signs.
  • Emergency call button/ bell
  • Required Posters (Emergency Disaster Plan (LIC 610E), Theft and Loss Policies, Visitors Policy, Personal Rights, rights of resident council, a Facility Sketch (LIC 999), and Complaint Information, Ombudsman).
  • Activity supplies (magazines, and games)
  • Fireplace Cover
  • Liability insurance

In addition, there were two individuals living at the home. Facility is not ready for licensure. LPA Nwogene will inform the Centralized Applications Bureau (CAB) that the home is ready for licensure when the missing items has been received and the two unauthorized individual has moved out.

An exit interview was conducted were this report was discussed with and provided to Daniel Blas.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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