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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200248
Report Date: 03/08/2024
Date Signed: 03/08/2024 03:38:57 PM

Document Has Been Signed on 03/08/2024 03:38 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: DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Henry Magtibay, AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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On 3/8/2024 at 12:20pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson conducted an unannounced annual 1-year required inspection. Administrator, Henry Magtibay, arrived at 12:35pm. and LPAs explained the purpose of the visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, and back yard. The facility consists of five (5) bedrooms and two (2) bathrooms. Staff occupies one (1) bedroom and one (1) room is used as an office. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 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 101.8 degrees Fahrenheit. All toilets were in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents.

Smoke detectors/carbon monoxide were in operating condition during visit. First aid kit was observed to be complete. Emergency disaster plan last updated 3/10/2023.

LPAs reviewed five (5) client files, all appraisal needs and services plan were outdated and none contained a consent for medical treatment form. LPAs reviewed three (3) staff files all was missing first-aid and CPR. LPAs also reviewed medication.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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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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: 03/08/2024
NARRATIVE
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Continued from LIC809.

The following forms to be updated and submitted to CCLD by 3/15/2024:
  • LIC610D Emergency disaster plan (all 9 pages)
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)

LPA observed the following deficiencies:
  • At 1:10pm, LPAs observed during record review that none of the staff have first-aid or CPR training.
  • At 1:30pm, LPAs observed during record all clients records did not obtain a current appraisal needs and services plan.
  • At 1:40pm, LPAs observed refrigerator was unsanitary.
  • At 2:00pm, LPAs observed facility have not conducted a fire drill.
  • At 2:15pm, LPAs observed during record review that clients' medication was not documented on medication administrative record (MAR).
  • At 2:20pm, LPAs observed during record review that Administrator does not have a current certificate.


The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/08/2024 03:38 PM - It Cannot Be Edited


Created By: Laura Hall On 03/08/2024 at 02:56 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BLESSED CARE HOME
FACILITY NUMBER: 079200248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in having a staff with an administrator certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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2
3
4
LPAs checked CCLD website and S1 and S2 administrator certificate shows pending. Deficiency cleared.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in having all staff first aid trained and at least per shift with CPR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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Administrator will get all staff trained and submit a copy of certificate 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: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/08/2024 03:38 PM - It Cannot Be Edited


Created By: Laura Hall On 03/08/2024 at 02:56 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BLESSED CARE HOME
FACILITY NUMBER: 079200248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(4)
Food Service
(4) Freezers and refrigerators shall be kept clean, and food storage shall permit the air circulation necessary to maintain the temperatures specified in (2) and (3) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having a sanitary refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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2
3
4
Administrator agreed to clean out refrigerator and submit a photo to CCLD by POC date.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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Administrator agreed to conduct a fire drill and submit a copy of sign-in sheet 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: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/08/2024 03:38 PM - It Cannot Be Edited


Created By: Laura Hall On 03/08/2024 at 03:20 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: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.2(b)(1)
80068.2 Needs and Services Plan


(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:

(1) The needs appraisal or IPP is not more than one year old.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in having an current appraisal needs and services plan for each client which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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Administrator agreed to complete an appraisal needs and services plan for each client and submit a self-certification that it has been done to CCLD by POC date
Type B
Section Cited
CCR
80075(b)(6)(c)
80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
(6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met:
(C) The date and time the PRN medication was taken, the dosage taken, and the client's response, shall be documented and maintained in the client's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in documenting the date, time, and dosage medicine was taken for each client which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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Administrator agreed to update the MAR for the month of March and going forward and submit a copy of each of the client's MAR 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: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


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