<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881468
Report Date: 03/25/2024
Date Signed: 03/25/2024 01:53:57 PM

Document Has Been Signed on 03/25/2024 01:53 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
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:
03/25/2024
TYPE OF VISIT:POCANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Daniel Blas, AdministratorTIME COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On today's date Licensing Program Analyst (LPA) Javina George conducted an announced Plan of Corrections-Pre licensing visit. LPA met with Daniel Blas and explained the purpose of today's visit. On 1/31/24 an initial pre licensing visit was conducted and the following items were noted to be missing:

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 Postings (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 and Liability insurance. The purpose of the visit was to verify the items noted above had been corrected.

LPA conducted a tour of the interior and exterior of the home. The facility is a single story home with a total of four (4) bedrooms, three (3) are designated for residents and one (1) is designated for a live in caregiver. There are a total of two (2) bathrooms, 1 of which is for resident use.

The hot water was tested in the resident bathroom and was found to be within regulatory limits as it was measured to be 118.7 degrees Fahrenheit. LPA observed 2 grabs bars and a nonskid mat inside the bathroom in the shower/bathtub.

Upon entry to the facility LPA observed the required postings such as the Emergency Disaster Plan (LIC 610E), Theft and Loss Policies, Visitors Policy, Personal Rights, rights of resident council, Facility Sketch and Complaint Information.



LPA observed a screened and locked fireplace inside the family room. LPA also observed for there to be games such as checkers, word searches, as well as other books available for the residents to use to promote and encourage socialization.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2024
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 2
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: 03/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Each resident bedroom was observed to have a chair, night stand, lamp and a chest of drawers. Additionally inside the resident bedrooms, each night stand was observed to have a bell, for the residents to use to alert staff when assistance is needed. LPA observed for there to not be any outlets in the hallway, however there were operable night-lights switches mounted on the wall. LPA observed for there to be a supply of towels and linens (comforters, and sheets) readily available for the residents to use.

LPA was provided proof Liability insurance was the obtained and was observed to be in effect 3/1/24-3/1/25.
LPA did not observe the two Males that were present on the visit that was conducted on 1/31/24. Per the Administrator Daniel, the home was being used as a room and board, and the two individuals have since vacated the premises.

However LPA observed for there to be a female individual/Staff #1 (S1) that is residing in the home and per Mr. Blas both he and S1 will both be running the home. LPA discussed the immediate need to have S1 obtain proper fingerprint clearance. LPA also discussed Guardian and having access as well as the need to ensure all individuals over the age of 18 that will be residing at the home and providing care and supervision to the residents have obtained proper fingerprint clearance and are associated to the facility.


Based on today's inspection the home is still not ready for licensure, as there is an uncleared individual (S1) residing in the home. LPA discussed the available options, which includes to have S1 vacate the premised and encouraged Mr. Blas to not accept any residents in the home until there are properly cleared individuals. All other noted missing items have been completed.

An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Daniel Blas.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2