<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200543
Report Date: 08/18/2022
Date Signed: 08/18/2022 04:05:03 PM


Document Has Been Signed on 08/18/2022 04:05 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:A BLISSFUL RETREAT, LLCFACILITY NUMBER:
079200543
ADMINISTRATOR:OSMAN, SUMAIYAFACILITY TYPE:
740
ADDRESS:4200 COWELL ROADTELEPHONE:
(925) 726-8888
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 0DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:24 PM
MET WITH:Sumaiya Osman, AdministratorTIME COMPLETED:
04:20 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 8/18/2022 at 1:00pm Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA knocked at the front door and rang the doorbell without an answer, LPA called the facility and Administrators cell phone and left a voicemail. Administrator returned call informed LPA that there are no residents at the facility and the business is in the process of being sold. LPA and Administrator met at the facility at 3:10pm.

On 08/18/2022 at 3:10pm Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct infection control inspection LPA met with administrator, Sumaiya Osman and explained the purpose of the visit

During the Infection Control Inspection, LPA toured facility including but not limited to common areas, kitchen, bedrooms, and shared bathrooms. to front entrance, screening station, hand washing stations, common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, a screening station was observed. Cough/sneeze etiquette, social distancing signs were posted in common areas. Hand washing posters, soap, and paper towel were observed at hand washing stations. Visitors policy is posted on the front door. Facility staff was observed wearing a mask. Facility has a 30-day supply of PPE maintained at a central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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 1