331880726-1-4-2024-56-AS-BWOT-CZ6S66-20240104123524

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880726
Report Date: 01/04/2024
Date Signed: 01/04/2024 12:35:33 PM

Document Has Been Signed on 01/04/2024 12:35 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BLISS HOMES		FACILITY NUMBER:	331880726
ADMINISTRATOR:	BHAMBHANI, BHAVNA		FACILITY TYPE:	740
ADDRESS:	6149 COOPERS HAWK DRIVE		TELEPHONE:	(714) 224-6763
CITY:	JURUPA VALLEY	STATE: CA	ZIP CODE:	91752
CAPACITY:	6	CENSUS: 6	DATE:	01/04/2024
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee Ashish Bhambani		TIME COMPLETED:	12:37 PM

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On 1/04/24, at 10:00 AM, Licensing Program Analysts (LPAs) Melody Brown & Bianca Wolcott made an announced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs Brown and Wolcott met with Licensee Ashish Bhambani was granted entry to the facility. At the time of the visit, Licensee Bhambani reported to LPAs Brown and Wolcott that there’s no resident at the home.

The facility is a (6) bedroom, (4) bathroom home with a kitchen/dining area, living room, and attached garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents and (6) may be bedridden, (2) hospice waiver and currently no residents at the facility. LPAs Brown & Wolcott were accompanied by Licensee Bhambani to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility will operate in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. Bathroom showers/bathtub are tiled. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperatures in the bathroom to be in 110 degrees F. The facility is equipped with

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BLISS HOMES	FACILITY NUMBER: 331880726
	VISIT DATE: 01/04/2024

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operating smoke detectors and carbon monoxide alarms. LPAs Brown & Wolcott observed no Infection Control plan available at facility, a Technical Violation (TV) was given.

Cleaning supplies, toxins, sharps, and other dangerous items will be kept inaccessible to residents in care. There was designated storage space for resident/staff files. There is a cabinet where they will store the residents’ medications and locked in the medicine room area. The facility has first aid kit and a first aid manual.

Food Service: No residents at the facility. Licensee Bhambini reported that they will have sufficient Non-perishable and perishable food supply for the number of residents in care, once they will have residents at the facility.

Care & Supervision-: The facility has an administrator present that will put sufficient hours to appropriately manage the facility. Licensee Bhambani reported to LPAs Brown and Wolcott that they will hire sufficient number of staff to appropriately provide care and supervision residents, once they will have residents at the facility.

Record Review: LPAs observed Licensee/Administrator Bhavna Bhambani has updated Administrator Certification and it will expire on 10/14/24. Licensee/Administrator also has updated First Aid/CPR Certification. No residents’ records to review as there’s no resident at the facility.

Based on the observations made during the visit today, LPAs Brown & Wolcott observed no Infection Control plan available at facility, a Technical Violation (TV) was given.

An exit interview was conducted, and this report (LIC809) and technical violation were discussed and provided to Licensee Ashish Bhambani.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Bianca Wolcott	TELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

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