<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920062
Report Date: 07/18/2024
Date Signed: 07/18/2024 01:02:16 PM

Document Has Been Signed on 07/18/2024 01:02 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: DATE:
07/18/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Caregiver & Baby Ofelia Quintero TIME VISIT/
INSPECTION COMPLETED:
01:10 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
Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a post-licensing inspection. LPA met with Staff and explained the purpose of the visit. Staff who then contacted Licensee, Baby Ofelia Quintero, who then arrived to the facility shortly.

During today's visit, LPA observed only two names, Licensee's and former Administrator are listed in facility roster via Guardian. Day prior to visit, LPA received email from former Administrator informing LPA his date of employment ended day of email. LPA did not received the required documents from Licensee for a change of facility administrator. However, Licensee provided proof of notification to CCLD's sactransferrequest.ca.gov email.

LPA observed S1 to be working at the facility with no background clearance association to facility roster, confirmed via Guardian. LPA was informed S2 has been appointed as Administrator, who has been an employee at the facility since operation but criminal clearance transfer was submitted to CCLD a day prior to visit. Licensee informed LPA that facility operation has been in effect for a month now. LPA provided facility CCR 22 87355 Criminal Record Clearance, section (c)(1) and (c)(2)(A-C) is needed to be submitted to CCLD. Licensee informed LPA of a bedridden resident inquiry, LPA informed Licensee a new fire inspection is needed for bedridden clearance as facility is licensed for six non-ambulatory residents only. Licensee agreed to submit LIC 200 and facility sketch to LPA for a new fire clearance request. LPA informed Licensee new admission of bedridden resident is restricted until new clearance approval.

LPA and Licensee conducted a tour of the facility and observed fire door to be hooked opened. LPA informed Licensee fire doors are to be closed at all times, if desired for fire door to be open, a magnetic door opener will need to be installed which is connected to fire alarm which will automatically release door when activated.

Deficiencies cited, please see LIC 809-D. Civil Penalties assessed. Exit interview and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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 3
Document Has Been Signed on 07/18/2024 01:02 PM - It Cannot Be Edited


Created By: Cassie Yang On 07/18/2024 at 11:55 AM
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 3
FACILITY NUMBER: 345920062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(c)
87355 Criminal Record Clearance
(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above as two staff were observed to be working at the facility since licensure but are not associated to the facility roster which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
Licensee is to submit the required documents to CCLD to transfer clearance to facility roster.
Licensee is to submit a statement of understanding that all staff are to be fingerprint cleared and associated to facility prior to employment.
Failure to provide POC by due date may result to civil penalty of $100 per day until received.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Anthony Perez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/18/2024 01:02 PM - It Cannot Be Edited


Created By: Cassie Yang On 07/18/2024 at 12:43 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 3
FACILITY NUMBER: 345920062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as LPA observed facility fire door to be hooked open which poses an immediate health, safety or personal rights risk to persons in care.
Failure to provide POC by due date may result to civil penalty of $100 per day until received.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
Licensee unhooked fire door immediately.
Licensee is to submit statement of understanding to obey fire safety law where fire doors are to be kept closed at all times.
Failure to provide POC by due date may result to civil penalty of $100 per day until received.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Anthony Perez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3