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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610346
Report Date: 11/10/2022
Date Signed: 10/10/2023 09:33:20 AM


Document Has Been Signed on 10/10/2023 09:33 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:BLESSED SENIOR LIVING CARE, LLCFACILITY NUMBER:
197610346
ADMINISTRATOR:VALDES, JENNIFERFACILITY TYPE:
740
ADDRESS:3244 ASHTON PLACETELEPHONE:
(818) 813-4403
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: DATE:
11/10/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Applicant/Administrator - Jennifer ValdesTIME COMPLETED:
12:00 PM
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Component II completion: Successful

Facility Type: Residential Facility for the Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): No
COMP II Participants: Applicant/Administrator - Jennifer Valdes
Interview Method: Telephone interview

On 11/10/22, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements/CPMB associations & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: madeline bowmanTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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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