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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700911
Report Date: 01/08/2025
Date Signed: 01/08/2025 03:33:52 PM

Document Has Been Signed on 01/08/2025 03:33 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:		ARAMBULO,LERIZAFACILITY TYPE:
740
ADDRESS:8538 KRANS CT.TELEPHONE:
(209) 834-4040
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 3DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator- Leriza ArambuloTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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On 01/08/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required 1 year annual inspection. LPA met with Administrator Leriza Arambulo and explained the purpose of the visit.

LPA and administrator conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured include but not limited to residents bedrooms, bathroom, kitchen and common areas. LPA observed facility to have required licensing posters. LPA observed medications, sharps, toxins to be locked and inaccessible to residents in care. LPA observed two (2) days of perishable and seven (7) days on nonperishable foods. LPA observed facility to be clean, sanitary and free of hazardous obstruction. Fire extinguisher was last serviced on 10/31/2024

LPA conducted file reviews for three (3) residents in care and two (2) personnel.

LPA and Administrator discussed the outstanding licensing fee from 2024 to current. LPA and Administrator completed the CARE tool and deficiencies was observed. Please see LIC809-D.

Exit interview conducted and a copy of the report and appeal rights were left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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 2
Document Has Been Signed on 01/08/2025 03:33 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 01/08/2025 at 03:24 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: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.185(b)(1)(F)
ยง1569.185 Fees for license or applications; use of revenues; collected; denial or forfeiture
(b) (1) In addition to fees set forth in subdivision (a), the department shall charge all of the following fees:
(F) A late fee that represents an additional 50 percent of the established current annual fee when a licensee fails to pay the current annual licensing fee on or before the due date as indicated by postmark on the payment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as LPA observed outstanding balance of $1,237 due to unpaid fee plus late fee assessed, which poses a potential health and safety risk for residents in care.
POC Due Date: 01/22/2025
Plan of Correction
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Licensee is to pay off the outstanding fee and submit proof of payment to LPA by POC due date.
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.
SUPERVISOR'S NAME:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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