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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 04:34:31 PM

Document Has Been Signed on 11/05/2024 04:34 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Baby QuinteroTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to open a complaint the Department received. LPA met with Licensee and explained the purpose of the visit.

When conducting the exit interview at approximately 1:15 PM, LPA and Licensee were interrupted by residents in care. R1 was sitting on the couch near the dining room, when became agitated. Licensee then gave R1 an apple to eat which R1 then mumbled words to Licensee and threw the apple onto the floor towards Licensee. Caregiver attempted to redirect R1 and gave R1 the apple again. LPA observed R1 throwing the apple again, breaking apart onto the floor. R1 then walked into the kitchen forcing cabinets and drawers to open. When Licensee attempted to redirect R1, R1 then punched the wall and informed Licensee to stay away.

In midst of R1's behavior, R2 was in the common area watching television. LPA observed R2 yelling at staff to change the channel. When dismissed, R2 became upset and walked towards the front door attempting to escape. LPA observed R2 shouting profanity and refusing to stay at the facility. Once R2 saw R1 was having behavioral issues, R2 walked to the dinning room to observe.

At this time when LPA, Licensee, S1, R1 and R2 were all present in the dining room, R1 walked around the table and hit Licensee with a closed fist. Due to safety precaution, LPA gathered her belongings and informed Licensee LPA will be in the car until the situation is handled. LPA advised Licensee to contact 911 as R1 is not on baseline. Licensee stated R1 is on hospice and she did not know if R1 can go to the hospital. LPA again informed Licensee that 911 should be contacted immediately for the health and safety of other residents in care as R1 should be evaluated.

LPA then vacated the facility to notify Licensing Program Manager of the following.

Please continue on LIC 809-C
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BLESSED HOMECARE 3
FACILITY NUMBER: 345920062
VISIT DATE: 11/05/2024
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LIC 809-C

Upon LPA's return to the facility, Licensee was no longer at the facility. LPA observed R1 to still be at the facility with hospice nurse.

LPA and Hospice Nurse discussed R1's change of condition. Hospice nurse stated at this time, it is strongly recommended for direct 1:1 care supervision as R1 can be erratic until R1 is further assessed.

The following incident will be under reviewed and further discussed by the Department.

Exit interview conducted and a copy of the report was provided. Due to Licensee no longer being at the facility, S1 has signed the following report, signature on this form acknowledges receipt.
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
LIC809 (FAS) - (06/04)
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