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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804216
Report Date: 05/06/2024
Date Signed: 05/06/2024 03:51:09 PM

Document Has Been Signed on 05/06/2024 03:51 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BLISSFUL CARE HOMEFACILITY NUMBER:
486804216
ADMINISTRATOR/
DIRECTOR:
BAILON, CLARIBELLEFACILITY TYPE:
740
ADDRESS:115 MICHAEL CT.TELEPHONE:
(707) 557-0180
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
05/06/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:14 PM
MET WITH:Claribelle Bailon, Administrator/ApplicantBlissTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Pre-Licensing Inspection and met with Applicant/Administrator, Claribelle Bailon.

Applicant has applied for a Change of Ownership at this location and currently has 6 residents in care. Facility is a one story residence with five resident bedrooms, 2 bathrooms, living room, dining room, kitchen area, two staff bedrooms and the garage. All resident rooms have the required furnishings in resident bedrooms. Bathroom showers have non-skid shower floors/mats and grab bars. Water temperature in bathrooms is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. The refrigerator was observed to be clean and there was plenty of perishable and Non perishable foods that appeared in good condition and stored properly. Cleaning supplies are locked under kitchen sink and locked. Sharps are located in kitchen drawer and locked. Personnel records and resident records are stored in locked cabinet. Medication is centrally stored and locked.

Facility received an approved fire clearance dated February 15, 2024Bli that allows for 6 non-ambulatory residents. Carbon monoxide and smoke alarms are operational. Fire extinguisher is charged and service 2/2024.
Required postings were observed, including a copy of the Admission Agreement. Auditory alarms on doors were operational.

Applicant to submit copy of Liability Insurance to Centralized Applications Bureau Analyst

Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation. Component III was conducted today, with Applicant, Claribelle Bailon. Pre-Licensing is complete. No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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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