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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881238
Report Date: 01/21/2025
Date Signed: 01/21/2025 02:23:59 PM

Document Has Been Signed on 01/21/2025 02:23 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/
DIRECTOR:		HERNANDEZ, CLAUDIAFACILITY TYPE:
735
ADDRESS:1275 BLAZEWOOD STREETTELEPHONE:
(951) 897-8114
CITY:RIVERSIDESTATE: CAZIP CODE:
92507
CAPACITY: 4CENSUS: 0DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Claudia Hernandez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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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 and visit purpose. Upon arrival LPA learned that there are no residents at this facility and there are no staff at this time. Facility is still awaiting to be vendorized through IRC. There is an Infection Control Plan on file.

Client Records-Incident Reports/Clients Rights-Information/Dental- There are currently no clients in care at this time.

Personnel Records/Training/and Staffing- LPA began review of employee records- One (1) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 11/20/2024, sent renewal in August, 2024 and awaiting for certificate in the mail.



Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals in a closet and sharps in the kitchen.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature. Lighting is sufficient for safety and comfort. Water temperature measured 106.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms and no bodies of water observed. (Continued on LIC809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BLAZEWOOD HOUSE
FACILITY NUMBER: 331881238
VISIT DATE: 01/21/2025
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(Continuation from LIC809)

Medications- There is an area to store medications in a locked cabinet. No medications were reviewed as there are no residents in care at this time.

P&I- There are no P&I to be reviewed as there are no client's in care at this time.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher was recharged last year, 12/20/2024. The facility is conducting emergency disaster/fire drills and the last one was done on 10/28/2024.

Based on the information received during this visit today in the areas reviewed, there are no deficiency are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809 report was reviewed with the facility representative and a copy was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
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