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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701304
Report Date: 04/02/2025
Date Signed: 04/03/2025 02:29:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/03/2025 and conducted by Evaluator Kesha Lewis
COMPLAINT CONTROL NUMBER: 27-AS-20250303092730
FACILITY NAME:A PLACE OF BLISSFACILITY NUMBER:
392701304
ADMINISTRATOR:IKISEH, CHUKWUDIFACILITY TYPE:
740
ADDRESS:10440 GRASS VALLEY CTTELEPHONE:
(209) 500-0990
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:6CENSUS: 6DATE:
04/02/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:IKISEH, CHUKWUDITIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff took inappropriate photo of resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver complaint findings for the above allegation. LPA was greeted licensee and explained the reason for the visit.

Allegation 1 Facility staff took inappropriate photo of resident is SUBSTANTIATED. Based on LPA interviews with reporting party, S1 and adminstrator, LPA found the allegation was true, R1'S responsible party was not asked and did not give approval for photos to be taken of R1. The Department has investigated the complaint listed above and based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be SUBSTANTIATED. As a result, the preponderance of evidence standard for this allegation is met, therefore, this allegation is SUBSTANTIATED.

Deficiencies cited see 9099D page per California Code Regulation, TITLE 22.

Exit interview was conducted and a copy of the report and appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20250303092730
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: A PLACE OF BLISS
FACILITY NUMBER: 392701304
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
04/14/2025
Section Cited
CCR
80071(a)(1)
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Each client shall have personal rights which include, but are not limited to, the following:..To be accorded dignity in his/her personal relationships …To be accorded safe, healthful and comfortable accommodations…This requirement was not met as evidenced by:
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 staff will complete mandated training with a focus on privacy. Administrator will email proof of training to LPA by COB 04/14/2025.
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Based on interviews, staff confirmed approval was not gained prior to taking the photo. which poses a potintial Health, Safety or 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2