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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700822
Report Date: 11/24/2020
Date Signed: 11/25/2020 03:47:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BLISSFUL GARDENFACILITY NUMBER:
092700822
ADMINISTRATOR:THAKUR, ANURAGFACILITY TYPE:
740
ADDRESS:4210 PRODUCT DRIVETELEPHONE:
(916) 673-6911
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:12CENSUS: 0DATE:
11/24/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Motuomanono Sokim, AdministratorTIME COMPLETED:
03:30 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 November 24, 2020, at 2pm, Licensing Program Analyst, (LPA) De Anna Williams-Lyons, conducted a tele Inspection with Motuomanono Sokimi, the Administrator, who assisted in conducting this Pre-licensing inspection. The facility is a single floor facility with 2 wings. Each wing has 6 bedrooms and 2 bathrooms. It has a capacity of 12. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 68 degrees F which is within range.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident's bedrooms and bathrooms, kitchen and dining room. In the kitchen area, Knives and sharp objects will be locked and made inaccessible to the residents at all times. The first aid kit was complete with scissors, thermometer, tweezers and a guide.The hot water temperatures was not taken, but will be in the future. There’s appropriate lighting throughout the facility. Dining room, and areas designated for residents use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident's bedrooms and bathrooms were toured. Not all Bedrooms had all the required items of furniture. About half of the rooms were empty so residents could possibly bring their own furniture. Window screens appeared to be in good repair. Bathrooms were clean and sanitary and consisted of grab bars and non-skid mats. The sinks, toilets, and showers operate properly.

Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. All fire extinguishers are maintained and ready for emergency use. Open porches and patios and areas of potential hazards accessible to residents, are equipped with sturdy hand railings.

To continue see 809-C...
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BLISSFUL GARDEN
FACILITY NUMBER: 092700822
VISIT DATE: 11/24/2020
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
LPA observed a medication room with locked cabinets and an area were files will be held. There are no medications or staff and client files available for review because the facility has no residents at this time. LPA also observed a large staff room.

LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. Indoor and outdoor passageways are free of obstruction and potential hazards. Construction is occurring next door due to the owner is having another facility being built, however, no potential hazards on the physical plant.

At the time of this inspection, the facility is in compliance and meets the minimum requirements for a RCFE license.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit.

Application is pending further review.

LPA will send a copy of report to the administrator to sign. Administrator to send a signed copy back to CCL and keep a copy for the facility records

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2