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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880637
Report Date: 01/29/2025
Date Signed: 01/29/2025 04:58:58 PM

Document Has Been Signed on 01/29/2025 04:58 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/
DIRECTOR:		ORLEANS, ROSALINDAFACILITY TYPE:
740
ADDRESS:284 ALDERWOOD WAYTELEPHONE:
(951) 776-8351
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Rosalinda Orleans, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card.

Resident record review began- Five (5) records were reviewed. LPA reviewed for admission agreement, medical assessment-1 not signed by Medical professional and TB test results-1 missing, consent forms-1 missing, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is not meeting documentation requirements.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 118.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location.



Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized.

LPA began review of employee records- Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met.
(Continued on next page)
Jazmond D HarrisTELEPHONE: (951) 248-0318
Yolanda DelgadoTELEPHONE: (951) 203-2990
DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 331880637
VISIT DATE: 01/29/2025
NARRATIVE
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The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged however according to the approved floor plan LPA observed an enclosed patio arrange for caregivers room with two beds, chest drawers, clothing, lamp and an exterior shed in the back yard with a sink, commode, a twin bed, and clothing and no smoke detector installed. Smoke detectors (1) installed in the kitchen is not operational and carbon monoxide detectors were tested; not operational. Fire extinguishers are tested or replaced annually and were last done so on 01/4/2025. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 01/25/2025.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, there five (5) deficiencies with Civil Penalties for $500 being issued, cited per Title 22, Division 6 of The California Code of Regulations.

This report, LIC809D, LIC421IM, Appeal Rights was reviewed with and a copy provided to the facility representative at the time of the exit interview.

LPA has requested updates to the following documents to be submitted to the CCL by 1/30/2025: Updated Facility sketch
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 01/29/2025 04:58 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 01/29/2025 at 04:13 PM
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: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in the floor plan observed did not match the layout of the facility, LPA observed an enclosed area with beds and furniture for two staff and an exterior shed in the back yard with bed, clothing, sink installed, commode, no smoke detector observed for a staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Licensee will submit an updated facility sketch. CCLD has requested an updated Fire Inspection from Fire Department. Licensee will email LPA an updated facility sketch by POC due date.
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation and interview the licensee did not comply with the section cited above in carbon monoxide detector was observed on wall of hallway however it was not operational which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Licensee will obtain a working carbon monoxide detector and install. LPA will return to verify.
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
TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME:Yolanda Delgado
TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/29/2025 04:58 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 01/29/2025 at 04:13 PM
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: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review the licensee did not comply with the section cited above in Resident #3 does not have a signed LIC602 by a medical professional which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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Licensee will obtain a signed LIC602 and email a copy to LPA by POC due date
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in Resident #4 file did not have TB documenation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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Licensee will ensure R#4 obtain TB documentation and email a copy to LPA by POC due date.
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
TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME:Yolanda Delgado
TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/29/2025 04:58 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 01/29/2025 at 04:13 PM
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: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(2)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in Resident #1 and Resident #2 is on Hospice and CCLD was not informed that residents was admitted to hospice which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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Licensee will email LPA by POC due date R1 and R2 notification of being admitted to Hospice care.

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
TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME:Yolanda Delgado
TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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