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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920062
Report Date: 11/19/2024
Date Signed: 11/19/2024 01:12:33 PM

Document Has Been Signed on 11/19/2024 01:12 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:
11/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Baby QuinteroTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Plan of Correction (POC) visit. LPA met with Licensee and explained the purpose of the visit.

During complaint investigation conducted November 5, 2024, facility was cited 87555 General Food Service Requirements with POC due date of November 12, 2024. LPA received an email of the requested POC on November 18, 2024. POC has been cleared and letter was generated. $600 failure to correct by due date civil penalty assessed.

Additionally, LPA cleared the following deficiencies that was issued during a case management visit conducted on November 5, 2024 and corrected in a timely manner, POCs has been cleared and letter was generated for the following:
- 87355 Criminal Record Clearance
- 87458 Medical Assessment

LPA and Licensee discussed the following POCs that is still accruing as POC has not been received and has exceeded its due date:

- ยง1569.312 Basic services requirements Type A violation POC due date of November 6, 2024 which facility is to submit a plan of how facility will ensure residents in care will not leave the facility unassisted/unnoticed. $1,300 failure to correct civil penalty has been assessed and will continue to accrue $100 per day until plan is received.

- 87405 Administrator - Qualifications and Duties Type B violation POC due date of November 15, 2024 which Licensee and Administrator are to review the provided handouts of CCR 87458 Medical Assessment
and CCR 87506 Resident Records and notify LPA once it has been completed. $400 failure to correct civil penalty has been assessed and will continue to accrue $100 per day until notification is received.

Exit interview, a copy of the report and civil penalty appeal rights provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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