079200248-3-30-2023-15-AS-LHAL-CQEVV6-20230330164548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200248
Report Date: 03/30/2023
Date Signed: 03/30/2023 04:46:08 PM

Document Has Been Signed on 03/30/2023 04:46 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 HOME		FACILITY NUMBER:	079200248
ADMINISTRATOR:	VICTORIA E. PALLERA		FACILITY TYPE:	735
ADDRESS:	72 RIVERVIEW DRIVE		TELEPHONE:	(925) 267-9162
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY: 6		CENSUS: 6	DATE:	03/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Henry Matigbay, Administrator		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/30/2023 at 01:15PM, Licensing Program Analysts (LPAs) L. Hall and C. Fowler conducted an unannounced annual required inspection. LPA met with Henry Matigbay, Administrator, and explained the purpose of the visit. Administrator arrived at 1:45PM. The facility’s fire clearance was approved for five (5) ambulatory and two (2) non-ambulatory clients. Administrator certificate (6013453735) expires 2/28/2024. LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) total bedrooms which one (1) is occupied by the staff, one (1) is an office. There are no bodies of water. A comfortable temperature for clients is maintained at 66 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 99.8 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper goods are sufficient. There is a minimum of 7-day non-perishables and 2-day perishables foods. Smoke detector/carbon monoxide was operable. Fire extinguisher was purchased 06/2022. Emergency Disaster Plan was last posted on 06/06/2022. First aid kit was observed to be complete. Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

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: 03/30/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued on LIC809C.

Three (3) staff files were reviewed, and all staff have criminal record clearance, first-aid, and CPR. All six (6) clients files reviewed. All files were missing consent form, personal safeguard, and five (5) need the appraisal needs and services plan updated. A sample of two (2) clients’ medications were reviewed.

The following forms to be updated and submitted to CCLD by 04/06/2023:

LIC 500 Personnel Report
Liability insurance
Client roster

LPA observed the following deficiencies:

At 2:15PM, LPAs observed wooden boards, head board, baby crib mattress, 2 hammers bed rail, ironing board, stationary bicycle, portable treadmill, 3 large car tires, roofing shingles, pallet, propane tank, and a large wrench.
At 2:25PM, LPAs observed patio screen in disrepair, and screen on rear bedroom window is missing.

The following deficiencies were observed (see LIC 809D) 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: 03/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 03/30/2023 04:46 PM - It Cannot Be Edited

Created By: Laura Hall On 03/30/2023 at 04:29 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: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(c)

Building and Grounds

(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having passageway in the backyard and on left side of home clear of debris which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2023
	Plan of Correction
1 2 3 4	Administrator agreed to have all debris removed and submit a photo to CCLD by POC date.

Type B

Section Cited

CCR

80088(b)

80088 Furniture, Fixtures, Equipment, and Supplies (b) All window screens shall be in good repair and be free of insects, dirt and other debris. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on(observation, the licensee did not comply with the section cited above in having patio screen in good condition and rear bedroom screens on windows which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2023
	Plan of Correction
1 2 3 4	Administrator agreed to repair patio screen and place screens on rear bedroom window. A photo shall be submitted 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: 03/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5