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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700822
Report Date: 05/23/2022
Date Signed: 05/23/2022 06:26:59 PM


Document Has Been Signed on 05/23/2022 06:26 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:BLISSFUL GARDENFACILITY NUMBER:
092700822
ADMINISTRATOR:JENNIFER SCARBERRYFACILITY TYPE:
740
ADDRESS:4210 PRODUCT DRIVETELEPHONE:
(530) 313-0364
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:25CENSUS: 16DATE:
05/23/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
05:05 PM
MET WITH:Jennifer Scarberry, AdministratorTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Praveen Singh arrived to conduct an unannounced Case Management inspection in relation to the Department receiving a priority complaint. Prior to initiating the inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA spoke with Administrator and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask.

LPA met with Administrator and discussed the purpose of the visit. During the inspection, LPA toured the interior of the facility including but are not limited to: common areas, dining area, and hallways. In the areas toured no immediate health and safety violations were observed. LPA observed passageways were free of obstruction. Administrator stated the facility is well equipped with personal protective equipment (PPE).

No deficiencies cited during inspection.

Exit interview conducted and copy of this report emailed to Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (310) 736-8689
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
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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