331881468-4-16-2026-18-AS-JTOS-DT7PWR-20260416114110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881468
Report Date: 04/16/2026
Date Signed: 04/16/2026 11:41:25 AM

Document Has Been Signed on 04/16/2026 11:41 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 LLC		FACILITY NUMBER:	331881468
ADMINISTRATOR/ DIRECTOR:	BLAS, DANIEL		FACILITY TYPE:	740
ADDRESS:	11964 WELBY PLACE		TELEPHONE:	(909) 636-8288
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY: 6		CENSUS: 5	DATE:	04/16/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	House Manager, Ahnna Hayes		TIME VISIT/ INSPECTION COMPLETED:	12:00 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 April 16, 2026, Licensing Program Analyst (LPA), Jarred Torres, arrived at the facility unannounced to conduct an annual inspection and met with House Manager, Ahnna Hayes. The Administrator, Daniel Blas, was unable to come to the facility due to transporting a new mattress from another city to the facility. A facility file review was conducted at the regional office and additional records were requested and reviewed at the facility. The facility is licensed for six elders and was operating at a census of five elders. The LPA toured the facility and made observations pertaining to the annual inspection. The LPA inspected the facility inside and outside. There were no obstructions on the indoor and outdoor passageways at the time of this visit. Additionally, there were no bodies of water on the premises. During the tour of the premises, the LPA observed the facility phone to be operable. The facility's phone number is 951-999-9212. The LPA observed the residents' bedrooms which were equipped with the required furniture as stated in Tittle 22 of the California Code of Regulations (CCR). The furniture in all areas of the facility was observed to be in good condition. The facility's appliances were observed to be operational at the time of this visit. Required postings regarding safety, personal rights, and emergency exits were posted in the home. Sharp items were kept locked and inaccessible to residents in care. The facility's cooling and heating system is operational and the air temperature was at 73 degrees Fahrenheit (F) and the hot water was measured at 119 degrees F. Continued on LIC 809-C...

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Jarred Torres
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

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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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: 04/16/2026

NARRATIVE

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The LPA observed the medications to be locked and inaccessible to clients in care. The medication supply was sufficient for the five clients in care. There were no discrepancies with the centrally stored medications.

In the kitchen, the food supply of non-perishable and perishable foods consisted of, but not limited to, bread, rice, pasta, frozen meats, vegetables, water, and fruits. The facility goes grocery shopping once per week and maintains an appropriate food supply for the five clients in care.

Adequate staff was present for the supervision of the five residents in care. The facility has a designated area for storing activity supplies and activities are conducted in the living room. Telephone numbers and floor plans were posted in the facility. The Administrator has a current administrator's certificate on file.

Client files and staff files were reviewed and no deficiencies were observed. Their files were stored in a secure location.

The LPA reviewed the emergency disaster plan and fire clearance at the regional office. The last fire drill was on March 1, 2026. The fire alarms and carbon monoxide detectors were tested and operational. The fire extinguishers were in good condition and were inspected on April 8, 2025. The emergency disaster plan meets the department's standards.

The LPA inspected the bathrooms and observed the hand washing stations to be stocked with soaps, bath tissue, and single-use hand towels. Furthermore, the bathrooms were free of dust and debris. Additionally, the facility has an approved infection control plan in their files.

An exit interview was conducted and this report was reviewed and provided to House Manager, Ahnna Hayes, whose signature on this form confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Jarred Torres
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC809 (FAS) - (06/04)

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