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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881468
Report Date: 04/02/2025
Date Signed: 04/02/2025 04:36:32 PM

Document Has Been Signed on 04/02/2025 04:36 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: 4DATE:
04/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:48 PM
MET WITH:Ahnna Hayes-House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to the facility to conduct a required annual inspection. LPA met with House manager Ahnna Hayes who was informed of the purpose of the visit. The facility has a fire clearance for six (6) ambulatory only and serves adults age range 60 and over. Waiver granted for hospice care for three (3). House Manager was the only staff present during the visit and has a criminal record clearance and is associated with the facility.

LPA toured the facility with House Manager and reviewed records. During the tour, LPA observed the facility is made up of a one (1) story home with three (3) resident bedrooms, one (1) staff room, two (2) bathrooms, a living room, dining room, kitchen and attached garage. All resident's bedrooms had required furniture and lighting. LPA toured the facility's exterior and observed outdoor pathways were free of obstructions. Outdoor shaded seating area is also available for the residents in care. LPA observed a hallway cabinet filled with clean towels, blankets, and linen, available for the residents. LPA toured the kitchen and observed the facility has a 2-day supply of perishable foods and more than a 7-day supply of non-perishable foods, which are stored in a safe and healthful manner. LPA toured the garage and observed an additional refrigerator with perishable foods. LPA also noted the facility secures additional cleaning solutions, laundry detergent, and disinfectants in the locked garage. House Manager tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. Medications are secured in a locked cabinet stored in the hallway closet. Exit signs, emergency contact information, resident's personal rights, and complaint information are visibly posted near the entrance.
NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Debbie Palacios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/02/2025
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Staff files reviewed include but not limited to have personnel records, required training, and valid first aid/CPR certification. Administrator Certificate is valid until 09/14/25. LPA was unable to review the facility's Fire Drill logs and earthquake drill due not having the physical document or file in the facility (Deficiency Cited). Resident files included but are not limited to signed admission agreements, pre-placement, personal rights, house rules, needs and service plans, and physician reports. Facility sketch, LTCO, CCL complaint poster, license and emergency disaster plan is posted on a wall in the living room.

Based on facility missing Fire and Earthquake drill documentation, a deficiency will be cited.

An exit interview was conducted. A copy of this report, LIC 809-D, and the appeal rights were provided to House Manager Ahnna Hayes.
NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Debbie Palacios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/02/2025 04:36 PM - It Cannot Be Edited


Created By: Debbie Palacios On 04/02/2025 at 03:59 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: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)


(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during the drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidence by:
Deficient Practice Statement
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Based on review on facility files, the licensee did not comply with the section cited above in conducting quaterly fire drills which poses/posed a potential health and safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Licensee agrees to conduct a fire drill with staff and will submit proof of the fire drill to LPA by the plan of correction date shown above. Licensee agrees to conduct quarterly fire drills for each staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Tricia Danielson
NAME OF LICENSING PROGRAM MANAGER:
Debbie Palacios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


LIC809 (FAS) - (06/04)
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