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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700911
Report Date: 10/30/2024
Date Signed: 10/30/2024 02:46:44 PM

Document Has Been Signed on 10/30/2024 02:46 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BLESSED HOMECAREFACILITY NUMBER:
342700911
ADMINISTRATOR/
DIRECTOR:		QUINTERO, E. BABY OFELIAFACILITY TYPE:
740
ADDRESS:8538 KRANS CT.TELEPHONE:
(209) 834-4040
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 2DATE:
10/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Caregiver Leriza ArambuloTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 10/30/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to conduct a case management visit. LPAs met with caregiver Leriza Arambulo and explained the purpose today's visit. Administrator Baby Ofelia Quintero was present at the facility for the first half of visit but had to leave and requested for caregiver to finish visit.

At the time of LPAs visit, one resident was out of the facility at the doctors. LPAs conducted a file review of two (2) resident files. Both resident files are complete with required paperwork. LPAs observed R1 to be taking two (2) PRN medications that are not listed on their medication list.

LPAs observed the facility to have a door stopper propping open the fire door in the hallway. LPAs also observed a fire extinguisher in the entry way of the facility that was last serviced on 01/25/23. LPAs also observed a fire extinguisher located in the residents hallway that was last serviced on 6/24/20.

PRN medications that are not listed on Resident medication list is a repeated violation as the following deficiencies was cited during an annual inspection on 01/10/24.

Deficiencies cited, civil penalties assessed.

Exit interview and a copy of the report and appeal rights left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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 10/30/2024 02:46 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 10/30/2024 at 01:28 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLESSED HOMECARE
FACILITY NUMBER: 342700911

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2024
Section Cited
CCR
87468(c)(2)(A)

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(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
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Licensee will post the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) in a common area. Picture of the poster posted to be sent into CCL by 11/13/24
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This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 posters which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to provide POC by due date may result to civil penalty of $100 per day until received.
Type B
11/13/2024
Section Cited
CCR87465(e)

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(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
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Licensee will obtain PRN prescriptions for R1s Probiotic and Stomach Relief with correct dosage. Licensee will come up with a plan on how to ensure PRN prescriptions are documented on medication list.
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This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents, PRN orders for Probiotics and Stomach Relief were not present in R1s file which poses a potential health, safety or personal rights risk to persons in care.
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Failure to provide POC by due date may result to civil penalty of $100 per day until received.
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:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2024 02:46 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 10/30/2024 at 01:31 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLESSED HOMECARE
FACILITY NUMBER: 342700911

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
CCR
87203

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
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Licensee immediately closed fire door and stated that the facility will keep it closed.
Licensee will send proof of service for both fire extinguishers to LPA.
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Based on observation, the licensee did not comply with the section cited above as LPAs observed facility fire door to be propped open with a door stopper and the fire extinguisher in hallway and entry way was last serviced on 06/24/20 and 01/25/23 which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to provide POC by due date may result to civil penalty of $100 per day until received.

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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:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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