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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200248
Report Date: 05/13/2022
Date Signed: 05/13/2022 04:52:51 PM

Document Has Been Signed on 05/13/2022 04:52 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BLESSED CARE HOMEFACILITY NUMBER:
079200248
ADMINISTRATOR:VICTORIA E. PALLERAFACILITY TYPE:
735
ADDRESS:72 RIVERVIEW DRIVETELEPHONE:
(925) 267-9162
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 5DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Henry Magtibay, CaregiverTIME COMPLETED:
05:10 PM
NARRATIVE
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On 5/13/2022 at 2:40PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA telephoned Caregiver on cell phone to come to facility. LPA met with Henry Magtibay, Caregiver at 3:10PM and explained the purpose of the visit.

Upon entry, LPA's temperature was not checked. LPA did not observe a screening station or sign-in booklets. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, and garage.. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and hand washing signs. Hot water temperature in the shared clients’ bathroom was measured at 107.4 degrees Fahrenheit.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 5/13/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BLESSED CARE HOME
FACILITY NUMBER: 079200248
VISIT DATE: 05/13/2022
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Continued from LIC809.

-LIC610D Emergency Disaster Plan
-An updated copy of Administrator certificate

The following deficiencies were observed:

-At 2:40PM, LPA observed a dishwasher and microwave sitting at the end of the driveway.
-At 3:30PM, LPA observed one 11x14 bedroom has been changed into a shared bedroom and one 11x14 bedroom has been changed into an office.
-At 3:40PM, LPA observed refrigerator outside on deck unsanitary.
-At 3:45PM, LPA observed fencing, part of a gate, dishwasher, shopping cart, rusted stable bicycle, and other items in back yard.
-At 3:50PM, LPA observed refrigerator in kitchen unsanitary.
-At 4:05, LPA observed fire extinguisher with no date or no receipt.

The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2022 04:52 PM - It Cannot Be Edited


Created By: Laura Hall On 05/13/2022 at 04:25 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BLESSED CARE HOME
FACILITY NUMBER: 079200248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 in having refrigerators unsanitary, outdated fire extinguisher, and fencing, dishwashers, microwave, and other items in front and backyard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
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Administrator agreed to clean refrigerators, purchase new fire extinguisher, dispose of dishwashers, microwave, shopping cart, bicycle, and other items and submit photo to CCLD by POC date.
Type B
Section Cited
CCR
80020(a)(1)
80020 Fire Clearance



(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
(1) The request for fire clearance shall be made through and maintained by the licensing agency.

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 in changing the bedroom from private to shared, and from private to office which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Administrator agreed to submit new facility sketch with LIC200 with changes to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


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