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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700822
Report Date: 09/14/2021
Date Signed: 09/14/2021 12:56:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:BLISSFUL GARDENFACILITY NUMBER:
092700822
ADMINISTRATOR:SHERI KIMBROFACILITY TYPE:
740
ADDRESS:4210 PRODUCT DRIVETELEPHONE:
(530) 313-0364
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:12CENSUS: 10DATE:
09/14/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sheri KimbroTIME COMPLETED:
01:00 PM
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Case management visit to increase facility capacity. Michael Smith LPA and Sheri Kimbro administrator were present. There are currently 10 residents. Facility was granted an increase in fire clearance from 12 to 25 residents on 8/5/21, for a total of 25 residents, in which 15 can be non-ambulatory and 10 bedridden seniors 60 and over. Administrator’s certificate expires on 1/25/22.

Facility was inspected both indoors and outdoors. Outdoors was clean, tidy with adequate shading. There are locked cabinets for personnel and client records. Facility has a First Aid kit and centrally stored locked cabinet for medication. Facility has appropriate linens for the bedrooms and baths. Bedrooms have adequate lighting and storage. Water faucets are marked hot and cold with the hot water temperature was measured at 107'. Smoke detectors were present. Facility has a fire suppression system throughout. Fire extinguisher indicators revealed a full charge. Toxins and chemicals are appropriately locked in a cabinet. Hazardous debris were noted in the far South West room which was locked upon inspection. The room shall be cleaned out and remain unoccupied until the debris are removed. LPA will return in 7 days to note the removal of items. This issue will not prevent the increase of capacity during today's visit.

All adults ages 18+ who reside here and are not clients, and all staff shall be fingerprinted and pass a criminal background check, prior to being present at the facility.

Upon return to the office, LPA will update facility license. A new license will be forwarded at that time.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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