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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881271
Report Date: 04/28/2022
Date Signed: 04/28/2022 11:35:21 AM

Document Has Been Signed on 04/28/2022 11:35 AM - 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:BLESS RESIDENTIAL CARE, LLCFACILITY NUMBER:
331881271
ADMINISTRATOR:OBI, BLESSINGFACILITY TYPE:
735
ADDRESS:1956 TUDOR DRIVETELEPHONE:
(619) 694-0971
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY: 4CENSUS: 0DATE:
04/28/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Blessing Obi, Licensee
Christina Campos, Designee		TIME COMPLETED:
11:50 AM
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Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPAs met with Licensee Blessing Obi and designee Christina Campos. An initial application to operate an Adult Residential Facility (ARF) was received by the Central Applications Bureau (CAB) on 11/17/2021 for a total capacity of four (4) ambulatory clients. Fire Clearance was granted for four (4) ambulatory clients on 2/14/2022. LPAs observed the following:
Structure:
Facility was a one story house with three (3) client bedrooms, two (2) bathrooms, family room, dining area and kitchen. There was an attached two car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each client bedroom will accommodate any ambulatory client. All client bedrooms were furnished with bed, chair, closet, adequate lighting, and an operable smoke alarm/carbon monoxide detector.
Bathrooms:
Both bathrooms have a working toilet, wash basin, and shower. At 11:00 AM, LPAs began testing water temperatures in client bathrooms. LPAs verified water temperatures were measured at 108 and 109 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies were secured in a locked cabinet in the laundry room. Knives/sharp instruments will be stored in a locked cabinet. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition
(CONTINUED ON LIC 812C)
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BLESS RESIDENTIAL CARE, LLC
FACILITY NUMBER: 331881271
VISIT DATE: 04/28/2022
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(CONTINUE FROM LIC809)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry area with washer and dryer were located in a separate room.
Living/Family room:
There was a family room with safe and adequate seating for all clients as well as working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in the hallway cabinet.
Yards/Outside:
Fencing secured the entire backyard. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property.
Garage:
Garage was fee of obstructions.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, emergency phone numbers, and facility sketch were posted in the kitchen/family room area.
General items:
Two (2) fire extinguisher were charged and mounted in kitchen and hallway. Smoke alarms/carbon monoxide detectors were tested and were in working order. Client records will be stored in a locked file cabinet. First Aid kit with required components, and locked area for medication storage was observed. There were no firearms or ammunition observed at the facility and LPAs were informed the facility will not store firearms or ammunition on the premises.
Component III was completely during today's visit and a hard copy was provided as well for future reference. Pre-Licensing is not complete at this time. The following corrections must be made in order to meet licensing requirements:
emergency flashlights
emergency food and water supply
signal system in client rooms
adequate clothing storage/dressers in each client room
gate to side of home must be self latching


An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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