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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881586
Report Date: 03/28/2025
Date Signed: 03/28/2025 10:16:14 AM

Document Has Been Signed on 03/28/2025 10:16 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BLISSFUL CANYON HOMECARE 3FACILITY NUMBER:
331881586
ADMINISTRATOR/
DIRECTOR:		ORLEANS, ROSALINDAFACILITY TYPE:
740
ADDRESS:7161 TIVERTON WAYTELEPHONE:
(951) 215-0143
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 4CENSUS: DATE:
03/28/2025
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA), Yolanda Delgado conducted an unannounced case management visit in regards to a capacity increase request. The LPA met with Administrator, Rosalinda Orleans. The facility is currently licensed for four (4) ambulatory clients, age 60 and over. The licensee is requesting to increase the capacity from four (4) ambulatory clients to six (6) non ambulatory clients. An approved STD 850 dated March 6, 2025 from the Riverside County Fire Department was submitted to Community Care Licensing for the increase in capacity.

The home consists of five (5) client bedrooms, two and half (2.5) bathrooms, a family room, a kitchen and dinning areas, a laundry and garage area, and outdoor space with shade and seating. The LPA toured the interior and exterior areas of the home. The home was clean and free of debris, the furnishings are suitable for clients. The client bedrooms are all equipped with the required furniture, and closet space, the kitchen was stocked with perishable and non perishable food items, and eating utensils to accommodate the six (6) clients. The medications will be centrally stored and locked in a medicine cart, all toxins were locked and inaccessible to clients. The LPA observed a first aid kit to be available. The LPA observed the required forms, and postings in the facility common areas. There was a room observed on the left interior of the garage with a door, enclosed with walls, ceiling light, electrical outlets, floor lamp, small lamp, toiletry supplies, blow dryer plugged into the electrical outlet, with personal belongings, clothing hanging on a stand, two dressers, rolled up mat with linen, pillows, tool boxes, small ladder, grey laundry basket, inside the garage during today's visit. The room is not on the facility sketch. A new license will be not be generated at this time and LPA will need to return to complete the inspection for increase in capacity when a new sketch and a new STD 850 is received to ensure room is in compliance with the Fire Department.

This report was reviewed with Administrator Rosalinda Orleans and a copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Yolanda Delgado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
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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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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