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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881238
Report Date: 01/09/2024
Date Signed: 01/09/2024 02:15:49 PM

Document Has Been Signed on 01/09/2024 02:15 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
RIVERSIDE ASC, 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:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Licensee/ Administrator, Claudia HernandezTIME COMPLETED:
02:20 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) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Claudia Hernandez, who was informed of the purpose of the visit. At the time of the visit there were (0) clients and (1) staff present.

The facility is a one story home with (2) bedrooms and (1) bathrooms with attached garage. The facility does have a pool or fire. The facility is designated as an adult residential home serving adults between the ages of 18-59 years of age. The facility has not had clients since licensure and is currently undergoing a vendorization process with Inland Regional Center. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted an interview. LPA observed the following:

Infection Control: LPA observed hand washing stations in the facility restrooms and kitchen had hand hygiene supplies, the facility has PPE equipment and cleaning supplies to do regular cleaning of the facility. There is an infectious disease plan for the facility.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility is the licensee's primary residency and observed staff rooms. The facility's outdoor area was observed to be free of hazards and contained outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. LPA observed where chemicals, sharps, and medication would be stored and locked. The smoke and carbon monoxide detectors were operational, and the hot water temperature read 105F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BLAZEWOOD HOUSE
FACILITY NUMBER: 331881238
VISIT DATE: 01/09/2024
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
26
27
28
29
30
31
32
Record Review and Resident/Staff Files: LPA reviewed the Guardian roster and the administrator/ Licensee's current administrator's certificate.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions.

No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to licensee, Claudia Hernandez.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2