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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920062
Report Date: 11/05/2024
Date Signed: 11/05/2024 01:25:45 PM

Document Has Been Signed on 11/05/2024 01:25 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:		ARAMBULO, LERIZAFACILITY TYPE:
740
ADDRESS:6350 SAMOA WAYTELEPHONE:
(209) 834-4040
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
11/05/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Baby QuinteroTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On November 5, 2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a proof of correction visit as during office meeting held on October 18, 2024 it was requested due by end of month, October 31, 2024 for Licensee to install a magnetic door opener as facility wants fire door to be open at all times. LPA met with Licensee and explained the purpose of the visit.

During today's visit, smoke detectors were activated in the common areas, hallway and residents room. LPA and Licensee observed that when activating the smoke detector in the common area next to the fire door, fire door does not automatically close. LPA informed Licensee that all smoke detectors in the facility should trigger the fire door to close for installation to be successful. LPA contacted Sacramento Metro Fire Inspector, Ryan Ono, to confirm the following deficiency.

Administrator stated when magnetic door opener was installed, smoke detectors from the common areas were not tested by Licensee and contractor.

Result of today's inspection, failure to correct civil penalty for of fire safety violation was accessed as installation was not correctly done.

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: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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