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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920062
Report Date: 08/20/2024
Date Signed: 08/20/2024 11:41:29 AM

Document Has Been Signed on 08/20/2024 11:41 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BLESSED HOMECARE 3FACILITY NUMBER:
345920062
ADMINISTRATOR/
DIRECTOR:		ARAMBULO, LERIZAFACILITY TYPE:
740
ADDRESS:6350 SAMOA WAYTELEPHONE:
(209) 834-4040
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 2DATE:
08/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Baby Ofelia QuinteroTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident Sacramento Metro Fire had observed during their inspection conducted on 8/16/2024. LPA met with Caregiver and explained the purpose of the visit.

Licensee then arrived to the facility shortly afterwards.

During Sacramento Metro Fire's inspection, it was observed that the fire door was defective and cannot self latch. Additionally, it was observed the smoke alarm in the hallway was disconnected. During LPA's visit, fire door was again hooked open against fire regulation. LPA informed Licensee that Metro Fire had highly advised that fire door should additionally install a magnetic door opener as this is LPA's second time observing the following deficiency. Licensee informed LPA smoke alarm has been ordered as the old smoke alarm did not fit.

During LPA's visit today, LPA observed S1 to be working at the facility with no criminal clearance association to the facility. LPA informed Licensee that all individuals working, residing and/or volunteering at the facility needs to have a fingerprint clearance and associated to facility roster. LPA was informed that S1 has started shadowing and/or orientation last week. LPA was additionally informed S2 has been working "here and there" and moved their personal belongings to the facility on Saturday August 17.

This is a repeated violation as the following deficiencies was cited during post-licensing inspection on 7/18/2024.

Deficiencies cited, civil penalties assessed.

Exit interview and a copy of the report and appeal rights provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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 08/20/2024 11:41 AM - It Cannot Be Edited


Created By: Cassie Yang On 08/20/2024 at 11:03 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: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2024
Section Cited
CCR
87355(c)

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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:
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S1 and S2 is to leave the facility until cleared and associated to the facility roster.
Informal meeting will be held to discuss this matter.
Failure to provide POC by due date may result to civil penalty of $100 per day until received.
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Based on observation and interview, the licensee did not comply with the section cited above as one staff was observed to be working and one staff was residing at the facility but are not associated to the facility roster which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
08/21/2024
Section Cited
CCR87203

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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 unhooked fire door immediately.
Licensee will input fire alarm up immediately and provide proof to LPA.
Licensee wil fix fire door to ensure it can self-latch.
Licensee will install a magnetic door opener as facility has the tendency to keep fire door opened.
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Based on observation, the licensee did not comply with the section cited above as LPA observed facility fire door to be hooked open and smoke alarm to be removed 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.
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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
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