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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920062
Report Date: 04/09/2024
Date Signed: 04/09/2024 12:28:39 PM

Document Has Been Signed on 04/09/2024 12:28 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 HOMECARE 3FACILITY NUMBER:
345920062
ADMINISTRATOR/
DIRECTOR:		PRASAD, SASHIFACILITY TYPE:
740
ADDRESS:6350 SAMOA WAYTELEPHONE:
(209) 834-4040
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 0DATE:
04/09/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Baby Quintero and Sashi PrasadTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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On 4/9/2024, Licensing Program Analyst (LPA) Cassie Yang arrived announced at the facility to conduct a pre-licensing inspection. LPA met with applicant, Baby Quintero and Administrator, Sashi Prasad, and explained the purpose of the visit.

During today's inspection, LPA conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: four residents bedrooms, two bathroom, laundry room, garage, kitchen, backyard, outdoor shed and the common areas. Facility is currently fire approved for six non-ambulatory, but LPA observed four beds to be installed only. It was discussed Room#1 and Room#2 may be arranged for shared couple rooms. LPA observed Room 1, 2, 3, and 4 to have the required items for personal accommodation.

Component III was waived as Administrator and applicant operated in previous facilities.

LPA provided the following copies to Administrator and Applicant, LIC 311F RECORDS TO BE MAINTAINED AT THE FACILITY- RCFE, LIC 624 UNUSUAL INCIDENT/INJURY REPORT, 87307 PERSONAL ACCOMMODATIONS AND SERVICES, 87621 COLOSTOMY/ILEOSTOMY and ยง1569.625 Staff training; legislative findings; contents

No deficiencies are being cited as a result of todays inspection. Facility is in significant compliance.

License is pending.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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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