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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601459
Report Date: 02/23/2023
Date Signed: 02/23/2023 01:10:32 PM


Document Has Been Signed on 02/23/2023 01:10 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:BLISSFUL CARE HOME LLC.FACILITY NUMBER:
015601459
ADMINISTRATOR:BUCTUAN-ROTOR, MARLYN & MAFACILITY TYPE:
740
ADDRESS:1381 VIA LA PALOMATELEPHONE:
(510) 278-0222
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY:6CENSUS: 2DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Marlyn Rotor-Buctuan, AdministratorTIME COMPLETED:
01:30 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 2/23/2023 at 11:30 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Administrator, Marlyn Rotor-Buctuan and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility with Marlyn including but not limited to front entrance, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2 day perishable and 7 day nonperishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins. Facility has a 30 day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan. Smoke and carbon monoxide detectors were observed and maintained. First Aid kit was complete. Fire extinguisher was observed serviced. LPA observed facility passages free of obstruction.

The following deficiency was observed during inspection:
-At approximately 11:35 AM LPA observed that S1 was not associated to the facility and did not have a current criminal record clearance.

The following deficiency was observed (see LIC 809 D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties

Exit interview conducted and a copy of this report provided along with Appeal rights.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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


Document Has Been Signed on 02/23/2023 01:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLISSFUL CARE HOME LLC.
FACILITY NUMBER: 015601459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)1)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above by having S1 work at the facility without a criminal record clearance nor association to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2023
Plan of Correction
1
2
3
4
Administrator will have S1 complete a criminial record clearance and associate them to the facility and provide photographic proof to ccl by POC date
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2