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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006367
Report Date: 05/07/2024
Date Signed: 05/07/2024 02:56:49 PM


Document Has Been Signed on 05/07/2024 02:56 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:BLISS CARE HOMEFACILITY NUMBER:
306006367
ADMINISTRATOR:NANDWANI, NIDHIFACILITY TYPE:
740
ADDRESS:2609 EAST SANTA YSABEL AVENUETELEPHONE:
(909) 964-6720
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:6CENSUS: 4DATE:
05/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Nidhi NandwaniTIME COMPLETED:
01:00 PM
NARRATIVE
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This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and RoseMarie Ruppert for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20240502150109. LPAs met with Administrator (AD) Nidhi Nandwani and discussed the purpose of the inspection.

During the course of the investigation, LPAs determined using the Licensing Information System that Staff #1 (S1) Cecilia Buscato is background cleared, but is not associated to facility #306006367 and has been working at the facility for for about three weeks per AD admission.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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Document Has Been Signed on 05/07/2024 02:56 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: BLISS CARE HOME
FACILITY NUMBER: 306006367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review .. shall prior to working, residing or volunteering in a licensed facility: … (2) Request a transfer of a criminal record clearance… This requirement was not met as evidenced by:
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Licensee stated they will associate S1 to the facility and submit proof to LPA by POC due date.
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Based on interviews and documents, the licensee did not ensure S1 was associated to the facility prior to working at the facility, which poses a potential 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.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2