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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700822
Report Date: 11/29/2022
Date Signed: 11/29/2022 11:58:13 AM


Document Has Been Signed on 11/29/2022 11:58 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: 14DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Motu SokimiTIME COMPLETED:
12:00 PM
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On 11/29/2022 Licensing Program Analyst (LPA) Lavinia Muscan, arrived at the facility unannounced to conduct an annual visit using the infection control tool visit. LPA met with Facility Administrator, Motu Sokimi and explained the purpose of the visit. Prior to initiating the visit, 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 ensured she used hand sanitizer shortly before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, outside area and common restrooms. Facility has a 2 day perishable and a 7 day non-perishable amount of food. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time. Facility has 14 residents 5 of which are on hospice.

Additionally, the facility submitted a capacity change for 46 non-ambulatory residents. On 11/23/22 a fire clearance was approved for the change. LPA inspected facility capacity change and approved. Changes will reflect in CCL Licensing System.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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