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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880637
Report Date: 12/06/2023
Date Signed: 12/06/2023 12:00:59 PM

Document Has Been Signed on 12/06/2023 12:00 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BLISSFUL CANYON HOME CARE IIFACILITY NUMBER:
331880637
ADMINISTRATOR:ORLEANS, ROSALINDAFACILITY TYPE:
740
ADDRESS:284 ALDERWOOD WAYTELEPHONE:
(951) 776-8351
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 6DATE:
12/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Rosalinda Olearns, AdministratorTIME COMPLETED:
12:15 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
Licensing Program Analyst (LPA) Yolanda Delgado conducted a visit for complaint number 18-AS-20231130084506 and during the visit, LPA reviewed documents, interviewed staff and toured the facility and it was revealed that Staff #1 (S1) did not have criminal background clearance and was not associated to the facility. LPA observed a wood glass coffee table blocking a passage way. There are working utilities, sufficient staffing and sufficient groceries for residents.

The following is being cited: Title 22, Division 6, Chapter 8, Article 05, Section s 87307(a)(6) and 87355(b).

The report was reviewed with Rosalinda and a copy of this report, LIC809D, LIC421BG, and Appeal Rights was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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 2
Document Has Been Signed on 12/06/2023 12:00 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 12/06/2023 at 11:37 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BLISSFUL CANYON HOME CARE II
FACILITY NUMBER: 331880637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2023
Section Cited
CCR
87355(b)

1
2
3
4
5
6
7
Criminal Record Clearance: (e) All individuals...shall prior to working, residing or volunteering in a licensed facility: (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to complete and submit the LIC9182 by 12/7/2023 in order for S1 to return at the facility. Licensee to provide LPA Delgado with proof of submitted request by 5pm on the due date indicated.
8
9
10
11
12
13
14
Based on observation and interviews, the Licensee did not comply with the above regulation with one staff (S1). LPA Delgado learned that S1 does not have a criminal record clearance and is not associated to this facility. This is an immediate safety risk to all residents in care.

8
9
10
11
12
13
14
Type B
12/06/2023
Section Cited
HSC87307(a)(6)

1
2
3
4
5
6
7
Personal Accommodations: (a) Living accommodations and grounds shall be related to the facility's function. The facility
shall be large enough to provide comfortable living accommodations and privacy for the
residents, staff, and others who may reside in the facility.
1
2
3
4
5
6
7
Licensee agrees to speak with staff and during the visit, staff moved the coffee table from obstructing the passage way.
8
9
10
11
12
13
14
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.Based on observation and interviews, the Licensee did not comply with the above regulation with a wood glass table pushed up to the front door of facility to block a resident from leaving. This is an immediate safety risk to all residents in care.

8
9
10
11
12
13
14
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2