306006367-12-27-2023-22-AS-DLMN-CYWPZ4-20231227104457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006367
Report Date: 12/27/2023
Date Signed: 12/27/2023 10:45:47 AM

Document Has Been Signed on 12/27/2023 10:45 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BLISS CARE HOME		FACILITY NUMBER:	306006367
ADMINISTRATOR:	NANDWANI, NIDHI		FACILITY TYPE:	740
ADDRESS:	2609 EAST SANTA YSABEL AVENUE		TELEPHONE:	(909) 964-6720
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY:	6	CENSUS: 3	DATE:	12/27/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Nidhi Nandwani - Administrator		TIME COMPLETED:	11:00 AM

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	Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection for a change of ownership. LPA arrived at the was greeted and granted entry by designated Administrator (AD) Nidhi Nandwani. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (2) ambulatory, (3) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 6/21/2023. Structure: The facility is a one-story home with five client bedrooms, two client bathrooms, living room, common area, kitchen, dining room, caregiver room, staff bathroom, detached two car garage, shaded patio and backyard. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the kitchen. There is a back yard with two exit gates. There is one shaded patio with seating area in the backyard. LPA did not observe any obstructions blocking the exit gates or obstacles or hazards in the backyard. Client Bedrooms: All client bedrooms have the required furnishings. LPA observed all resident beds have linens and blankets. LPA observed all windows were screened. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and are stored and locked in the garage. Medications, First-Aid Kit & Book: Medication and first aid kit are stored in a closet in the living room.. First aid kit is stored with the medication. The first aid kit has all the required elements. Resident & Staff Files: Records will be locked in the designated caregiver space in the living room.. Component III: Component III was provided to cover information regarding maintaining compliance.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BLISS CARE HOME	FACILITY NUMBER: 306006367
	VISIT DATE: 12/27/2023

NARRATIVE

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Fire Extinguisher: LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed a service tag for the fire extinguisher which indicates the fire extinguisher was last serviced on 7/13/2023

Activities: The facility hosts movie nights, sports nights and game nights for the residents.

Fire clearance: Was approved by a fire inspector of Fullerton Fire Department on 8/31/2023.

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water initially measured above 120 degrees Fahrenheit. Staff adjusted hot water heater and LPA waited for the hot water to drain from the tank. LPA measured the water again and observed the hot water to measure 105.2 degrees Fahrenheit in both bathrooms. LPA advised applicant to monitor the water in resident bathrooms since measurements are so close to the minimum.

Linens & Hygiene Supplies: A supply of extra linen is stored in cabinets in the hallway and one of the resident bathrooms.

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review.

Food Service: There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors: Smoke detectors and Carbon Monoxide detectors are stationed throughout the home. Both types of detectors were tested and observed to be operational.

Appliances: Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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