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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881238
Report Date: 01/20/2023
Date Signed: 01/20/2023 02:03:32 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/20/2023 02:03 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:BLAZEWOOD HOUSEFACILITY NUMBER:
331881238
ADMINISTRATOR:HERNANDEZ, CLAUDIAFACILITY TYPE:
735
ADDRESS:1275 BLAZEWOOD STREETTELEPHONE:
(951) 897-8114
CITY:RIVERSIDESTATE: CAZIP CODE:
92507
CAPACITY: 4CENSUS: 0DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee and administrator, Claudia HernandezTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct an annual inspection with a focus on infection control. LPA met with the licensee Claudia Hernandez who was informed of the purpose of the visit. The licensee stated that the facility currently has no residents.


LPA took a tour of the facility's interior and exterior. LPA was informed of by who the facility's infection control lead, and how they plan to mitigate COVID when they acquire residents. LPA reviewed the facility's infection control plan and mitigation plan. LPA observed a central entry point for facility visits. Hand sanitization is requested upon entry, and licensee was wearing a mask during the visit.

LPA observed the resident rooms that would be used as isolation rooms and the facility bathrooms that would be used by the residents.

NO deficiencies were cited at the time of the visit.

An exit interview was conducted where this report was reviewed and provided to Licensee, Claudia Hernandez.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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