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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 04:29:03 PM

Document Has Been Signed on 11/05/2024 04:29 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:
12:00 PM
MET WITH:Baby QuinteroTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On November 5, 2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident reported to the Department on November 4, 2024. LPA met with Licensee and explained the purpose of the visit.

The incident occurred on November 4, 2024 when R1 wanted to speak to their family member who was currently unavailable. R1 became agitated and was walking back and forth from room to dining room. Staff then observed front door to be open at 9:38AM. S1 stated R1 was not observed in sight near the facility, S1 then contacted 911 to report missing persons.

Local Law Enforcement then observed R1 to be a block away from the facility. LPA requested R1's LIC 602 for review but facility does not have the following.

As a result of today's visit, please see LIC 809-D.

Exit interview conducted an a copy of the report and appeal rights 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
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 11/05/2024 04:29 PM - It Cannot Be Edited


Created By: Cassie Yang On 11/05/2024 at 12:00 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: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2024
Section Cited
HSC
1569.312(e)

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ยง1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement is not met as evidenced by:
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Licensee shall provide a plan to LPA of hoe facility will ensure residents in care will not be absent without leave. Plan is to be provided to LPA by 11/6/2024.

Failure to correct may result to $100 per day until received and/or corrected.
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Based on file review of the incident report and interview, Licensee did not comply as R1 left the facility through the front door without staff seeing which poses an immediate health and saftey risk.
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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: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
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