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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194701019
Report Date: 05/21/2026
Date Signed: 05/22/2026 07:44:32 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/22/2026 07:44 AM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:A&K BLISSFUL HOME CARE, LLCFACILITY NUMBER:
194701019
ADMINISTRATOR/
DIRECTOR:		ASQUITH WILLIAMSFACILITY TYPE:
300
ADDRESS:301 N LAKE AVE #600TELEPHONE:
(323) 800-8602
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: CENSUS: DATE:
05/21/2026
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Justin Rayside - DesigneeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Enforcement Analyst (EA), Ryan Chan, with the Home Care Services Branch (HCSB) conducted a virtual visit for the purpose of a biennial inspection. The proper posting of business hours and license was observed during the virtual tour of the facility.

During the inspection, EA reviewed personnel records for Home Care Aides (HCA) including fingerprint status', registry status', tuberculosis (TB), and required training. The Home Care Organization’s (HCO’s) business records were also reviewed during the visit including the insurance requirements. Upon completion of the file review EA discussed the findings of the inspection with the designee. EA informed the designee of the deficiencies found and explained they would be noted on the 809D.

An exit interview was conducted, a copy of this report and appeal rights were provided to the designee via email.

NAME OF LICENSING PROGRAM ANALYST: Ryan Chan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2026 07:44 AM - It Cannot Be Edited


Created By: Ryan Chan On 05/21/2026 at 05:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
Although this visit/inspection may have focused on the review of specific licensing requirements, the applicant/licensee must comply with all applicable requirements. The California Department of Social Services retains authority to issue citations or take disciplinary action for any deficiency.


FACILITY NAME: A&K BLISSFUL HOME CARE, LLC
FACILITY NUMBER: 194701019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2026
Section Cited
1796.42(d)
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1796.42(d) Maintain proof of general and professional liability insurance in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the aggregate.
This requirement is not met as evidenced by:
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Based on records reviewed licensee did not ensure HCO had proper general and professional liability insurance which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
LICENSING EVALUATOR NAME: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2026
LIC809 (FAS) - (06/04)
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