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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881468
Report Date: 01/14/2025
Date Signed: 04/03/2025 01:12:49 PM

Document Has Been Signed on 04/03/2025 01:12 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/
DIRECTOR:		BLAS, DANIELFACILITY TYPE:
740
ADDRESS:11964 WELBY PLACETELEPHONE:
(909) 636-8288
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 5DATE:
01/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Ahnna Hayes-House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Debbie Palacios conducted a case management visit to address concerns regarding the facility not having resident's files/records available at the time of the visit. The LPA met with House Manager (HM) Ahnna Hayes and informed her the purpose of the visit.

During the time of the visit, LPA was unable to review resident and staff record's; House Manager (HM) Ahnna reported to LPA that the resident's records were inaccessible due to Director Daniel Blas having them in his possession. Director Daniel Blas was not present during this visit due to family emergency.



Based on resident files not being available at the facility, a deficiency will be cited for not having resident records available for review.

An exit interview was conducted and a copy of this report was provided along Appeal Rights.
NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Debbie Palacios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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Document Has Been Signed on 04/03/2025 01:12 PM - It Cannot Be Edited


Created By: Debbie Palacios On 01/14/2025 at 03:18 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BLAS HOMES LLC
FACILITY NUMBER: 331881468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2025
Section Cited
CCR
87506(a)

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87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. Staff were unable to provide LPA with resident records, as they did not have access to them.
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Licensee must provide proof that resident records are readily available to facility staff and to licensing agency staff by the POC date of 1/31/25.

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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:Tricia Danielson
LICENSING EVALUATOR NAME:Debbie Palacios
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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