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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920062
Report Date: 11/18/2024
Date Signed: 11/18/2024 01:20:19 PM

Document Has Been Signed on 11/18/2024 01:20 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: 4DATE:
11/18/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Baby Quintero and Leriza ArambuloTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On November 18, 2024, an office meeting held at the Sacramento North Regional Office located at 9835 Goethe Road, Suite 100, Sacramento CA 95827. LPA met with Licensee and explained the purpose of the visit.

During Proof of Correction visit on November 5, 2024, LPA 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 informed Licensee that plan of correction is not completed, and Licensee will need to submit a video of completion to LPA as $100 per day until corrected will accrue.

On November 13, 2024, LPA received a text message from Licensee of correction. Licensee explained that video was sent prior on November 11, 2024 but it was not delivered. Based on the video time stamp of video, LPA observed it to be taken on November 10, 2024 at 8:18PM.

LPA has agreed to clear the POC for the following date the video was taken.

$500 civil penalty for failure to correct by POC due date was assessed.

Exit interview and a copy of the report and civil penalty appeal rights provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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