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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920062
Report Date: 03/25/2025
Date Signed: 03/25/2025 12:13:20 PM

Document Has Been Signed on 03/25/2025 12:13 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:
03/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Baby QuinteroTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual visit utilizing the care tool. LPA met with Licensee and explained the purpose of the visit.

Today's census is five residents in care with two residents on hospice services. Facility is in compliance to licensure.

LPA and Licensee conducted a tour of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: four residents bedrooms, kitchen, garage, backyard and the common areas. LPA observed the garage to have beddings and personal belongings. LPA was informed the garage is occupied as a "resting" space for staff when they are on break. Licensee denied any live in staff at the facility. During inspection of the exterior, LPA observed pathway to be obstructed with gardening tools and recycling boxes. LPA informed Licensee pathways cannot be obstructed. LPA provided Licensee a copy of CCR 87307.

File review was conducted. Emergency Disaster Plan was reviewed, LPA informed Licensee plan should be reviewed and/or updated every year along with signature. LPA provided Licensee a copy of LIC 610E. Fire Drill was reviewed, LPA observed fire drills conducted for October and November 2024. LPA informed Licensee fire drills need to be conducted quarterly with all staff in every shift. File review of personnel files, LPA observed S1 and S2 to have no first aid certification. LPA informed Licensee that all caregivers are to have first aid and at least one person per shift needs CPR certification.

LPA was unable to complete full care tool today. LPA will return at a later date to complete the inspection.

Deficiencies cited. Exit interview and a copy of the report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
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 03/25/2025 12:13 PM - It Cannot Be Edited


Created By: Cassie Yang On 03/25/2025 at 11:43 AM
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: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as fire and earthquake drills has not been conducted quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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Licensee will create a drill schedule to be in compliance and provide a copy to LPA Yang by April 4, 2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/25/2025 12:13 PM - It Cannot Be Edited


Created By: Cassie Yang On 03/25/2025 at 11:51 AM
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: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as LPA osberved two staff files that did not have first aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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Licensee is to conduct an audit of staff files to ensure all caregivers have a first aid certification.
Licensee is to provide proof of S1 and S2's first aid by April 4, 2025.
Type B
Section Cited
CCR
87307(d)(6)
87307 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed gardening tools and recycling boxes located on the exterior pathway which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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Items were removed immediately.
Licensee is to provide LPA a statement of compliance of the following regulation.
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: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
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