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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200248
Report Date: 07/14/2022
Date Signed: 07/14/2022 03:52:09 PM

Document Has Been Signed on 07/14/2022 03:52 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:
07/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Henry Magtibay, CaregiverTIME COMPLETED:
04:00 PM
NARRATIVE
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On 7/14/2022 at 3:10PM Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 7/8/2022. LPA met with Henry Magtibay, Caregiver and explained the purpose of the visit.

Incident report was sent on 7/11/2022 after elopement. LPA requested C1's file. Facility did not have a file for C1. S1 stated that C1 did not want to sign any paperwork. S1 will confirm with Pittsburg Police Department if C1 was entered as a missing person. S1 stated that staff looks for C1 everyday.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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 2
Document Has Been Signed on 07/14/2022 03:52 PM - It Cannot Be Edited


Created By: Laura Hall On 07/14/2022 at 03:36 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: 07/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2022
Section Cited
CCR
80070(a)

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80070 Client Records (a) The licensee shall ensure that a ...complete, and current record is maintained in the facility for each client. This requirement was not met as evidence by:
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Administrator agreed to review Regulation 80070 Client records and submit a self-certification that the regulation has been reviewed and administrator will abide by the regulation going forward. Self-certification will be submitted by the POC date.
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Based on LPA's observation and records review the Licensee did not comply with the section cited above in maintaining complete records for C1 which poses a potential health and safety 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022


LIC809 (FAS) - (06/04)
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