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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700822
Report Date: 10/31/2022
Date Signed: 10/31/2022 09:22:59 AM


Document Has Been Signed on 10/31/2022 09:22 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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: 13DATE:
10/31/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Motu Sokimi, AdministratorTIME COMPLETED:
09:25 AM
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Licensing Program Analysts (LPA) Lavinia Muscan conducted unannounced case management visit on 10/31/2022. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES.

LPA met with Administrator and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective 10/31/2022 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility.

Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
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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