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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002812
Report Date: 09/27/2023
Date Signed: 09/27/2023 02:44:45 PM


Document Has Been Signed on 09/27/2023 02:44 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:BLESSED HOMECARE 2 ROSEVILLEFACILITY NUMBER:
315002812
ADMINISTRATOR:ARGANA, FERDINANDFACILITY TYPE:
740
ADDRESS:4100 SHORTHORN WAYTELEPHONE:
(209) 834-4040
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
09/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Baby QuinteroTIME COMPLETED:
02:55 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
LPA Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with Licensee Baby Quintero.

This facility has four resident rooms; two shared and two private. None of the rooms have exits to the outside. There is no staff room so the facility shall have 24 hour awake night staff. The main entrance opens into the hallway that has the resident rooms and locked laundry room. Directly to the left is a door that leads to the garage. To the right is a short hallway that leads to one shared room, one private room, and a full common bathroom that has a shower with nonskid floor and appropriate grab bars. On the right past the door leading to the garage is a private resident room with a full private bathroom. Past the short hallway on the right of the main entrance is another short hallway that leads to the right and the final shared resident room with a full private bathroom. The kitchen, dining, and main common area is located in the back of the facility. There is a sliding glass door leading to the outside. The kitchen has a locked cabinet for sharp knives. Laundry room has a locked cabinet for medications and small refrigerator for medications and a cabinet for the resident and staff files. There are gates on both sides of the facility.

-six resident records were reviewed
-three staff files were reviewed

The following shall be updated and submitted to Community Care Licensing by 10/15/2023:
-LIC 500 facility personnel or staff schedule
-LIC 610 emergency disaster plan
-LIC 308 designation of administrative responsibility

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023
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 1