331881271-5-17-2023-18-AS-CNWE-CRWNJH-20230517103021

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881271
Report Date: 05/17/2023
Date Signed: 05/17/2023 10:30:29 AM

Document Has Been Signed on 05/17/2023 10:30 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BLESS RESIDENTIAL CARE, LLC		FACILITY NUMBER:	331881271
ADMINISTRATOR:	OBI, BLESSING		FACILITY TYPE:	735
ADDRESS:	1956 TUDOR DRIVE		TELEPHONE:	(951) 392-3814
CITY:	SAN JACINTO	STATE: CA	ZIP CODE:	92583
CAPACITY: 4		CENSUS: 0	DATE:	05/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Victor Akinbayode		TIME COMPLETED:	10:35 AM

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On 5/17/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Licensee's Husband, Victor Akinbyode who was informed of the purpose of the visit. At the time of visit there was 0 staff and 0 residents present. LPA toured the facility inside and out with Victor.

Tour included:

Kitchen; LPA toured the kitchen and only observed emergency food and water. Victor stated facility currently has no clients. Victor stated 7-day supply of non-perishable and 2-day supply of perishable foods will be available when clients are admitted. LPA observed utensils and dishware are sufficient. The refrigerator and stove are in working order. Sharps are stored in kitchen cabinet, available only to authorized individuals. Trash cans has tight-fitting lid. Dishwasher will be used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition.

Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medications; Due to no clients in care, no medication was observed. LPA observed the first aid kit to be complete.

Continue on LIC809-C

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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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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: BLESS RESIDENTIAL CARE, LLC	FACILITY NUMBER: 331881271
	VISIT DATE: 05/17/2023

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Continued from 809

Bathroom; LPA toured two #2 out of #2 bathrooms in the facility and observed bathrooms to be clean. There is also a good number of personal toiletries available for the residents. The hot water measured at 116 degrees Fahrenheit.

Bedroom; LPA toured Three #3 out of #3 residents bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting.

Laundry; LPA toured the laundry room and observed laundry room to be clean. Washing machine and dryer are all in good repair and sufficient for the approved census. Cleaning supplies will be stored away in the laundry room, inaccessible to clients.

Garage; LPA tour the garage and observed garage to be clean and not cluttered.

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gates remain unlocked. No bodies of water were observed.

Records: All required postings, including COVID’s postings, were posted near the entryway and throughout the facility.

Interview; No interview was conducted because there was no client and no staff present.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed with and provided to Victor Akinbayode.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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