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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005903
Report Date: 07/22/2021
Date Signed: 07/22/2021 04:40:35 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/22/2021 04:40 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BLESSED HOME FOR SENIORS INCFACILITY NUMBER:
347005903
ADMINISTRATOR:MERCIDITAS GALITOFACILITY TYPE:
740
ADDRESS:7619 KILLDEER WAYTELEPHONE:
(916) 896-0824
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 3DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Aurora GatchalianTIME COMPLETED:
05:00 PM
NARRATIVE
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On 7-22-21 Licensing Program Analysts (LPA)s Tirzah Hubbard and Avelina Martinez conducted an unannounced Annual visit. LPAs met with Administrator and Licensee Aurora Gatchalian to discuss the purpose of the visit.

LPAs observed the facility in renovation. Administrator stated,
"The facility has been in renovation for 2.5 weeks. The residents were transferred to Blessed Home for Seniors IV. A total of 3 residents were transferred. The families were not notified. Employees were transferred over to Blessed Care Home for Seniors IV.

LPAs observed CCL has not been notified of the changes in renovation, staff transfer, and resident transfer. LPA Hubbard observed an email sent to LPA Yang 2/9/20. The email to LPA Yang contained questions about steps in renovating and transfer of residents and staff. LPA Yang requested a 60 day notice to residents family and CCL before renovation on 2/3/2020.

LPA observed Administrator Aurora did not submit 60 day notice to CCL or Residents family.
LPA Hubbard observed an email sent July 10,2020 from Administrator Aurora asking about renovation. The email did not contain renovation dates and transfer information for staff and residents. The email did not contain the requested 60 day notice to families or CCL.LPAs observed staff and residents were transferred over to Blessed Home for Seniors IV July 5, 2021.

Census: 3

Continued...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BLESSED HOME FOR SENIORS INC
FACILITY NUMBER: 347005903
VISIT DATE: 07/22/2021
NARRATIVE
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On 7-22-21 Administrator Aurora stated,
Renovation start date: July 5, 2021
Renovation end date: July 22.2021
Residents and staff will be back into the facility on July 26, 2021.

LPAs observed no finger print clearance for S1. LPAs observed no documentation of proof showing the residents family were notified within 60 days of renovation and return.

LPA's requested Mitigation plan to be submitted to the department within 48 hours.

Upon a file review the following items were discussed to be submitted with any changes annually:
Licensing fees
Criminal Record Clearances LIC536
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Qualifications of Administrator/Facility Manager- Administrator certificate
Emergency Disaster Plan LIC610D

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2021 04:40 PM - It Cannot Be Edited


Created By: Tirzah Hubbard On 07/22/2021 at 03:56 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BLESSED HOME FOR SENIORS INC
FACILITY NUMBER: 347005903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2021
Section Cited
CCR
80019(e)(1)

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Record Review
80019(e)(1) All staff must have a criminal record clearance or a criminal record exemption.

This requirement was not met as evidence by:
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Licensee will submit a revised LIC421 for each care giver associated with the facility.
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Licensee did not ensure all staff to have finger print clearnace in order to work in facility which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
07/22/2021
Section Cited
CCR87223(a)(2)

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Relocation of Resident
87233(a)(2) When a resident must be relocated by Department order...(2) contacting the person responsible for the resident to assist in transporting him or her, if necessary.

This requirement was not met as evidence by:
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Licensee will notify the persons responsible for residents to assist in transporting.
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Licensee did not notify the residents family of relocation to another facility during renovation of facility.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2021 04:40 PM - It Cannot Be Edited


Created By: Tirzah Hubbard On 07/22/2021 at 04:10 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BLESSED HOME FOR SENIORS INC
FACILITY NUMBER: 347005903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2021
Section Cited
CCR
87211(d)

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Reporting Requirements
87211(d) The licensee shall notify the Department, the State Long-Term Care Ombudsman, all residents, and, if applicable. their representatives, in writing..

This requirement is not met by evidence by:
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Licensee will notify CCL, LTC, and Representatives of persons in care of renovation and relocation changes.
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Licensee did not notify CCL, Representativces of persons in care, and LTC which poses an immediate health,safety, and personal rights risk to persons in care.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021


LIC809 (FAS) - (06/04)
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