331881586-7-8-2024-18-AS-YDEO-D6YUN2-20240708154314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881586
Report Date: 07/08/2024
Date Signed: 07/08/2024 03:43:25 PM

Document Has Been Signed on 07/08/2024 03:43 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:	BLISSFUL CANYON HOMECARE 3		FACILITY NUMBER:	331881586
ADMINISTRATOR:	ORLEANS, ROSALINDA		FACILITY TYPE:	740
ADDRESS:	7161 TIVERTON WAY		TELEPHONE:	(951) 215-0143
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92506
CAPACITY:	4	CENSUS: 0	DATE:	07/08/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Rosalinda Orleans, Licensee/Administrator		TIME COMPLETED:	04:00 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) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 1:35 PM, LPA met with Licensee/Administrator Rosalinda Orleans. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 5/2/2024 for a total capacity of four (4); three (3) non-ambulatory and one (1) ambulatory residents. Fire clearance was granted on 5/16/2024. LPA Delgado observed the following: Structure: Facility was a one-story house with four (4) resident bedrooms, one and half (1.5) resident bathrooms, staff room, living room, dining area and kitchen. There was an attached three 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 resident bedroom #2, #3 and #4 will accommodate any non-ambulatory resident, bedroom #1 will accommodate one ambulatory residents. Four (4) resident bedrooms were adequately furnished with bed, chair-3 missing, closet, appropriate linens, adequate lighting, and an operable smoke alarm. (Continued on Page 2)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

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: BLISSFUL CANYON HOMECARE 3	FACILITY NUMBER: 331881586
	VISIT DATE: 07/08/2024

NARRATIVE

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(Continued from Page 1)

Bathrooms:
The one and half (1.5) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 2:20 PM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 118.3 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the garage. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition, washer and dryer was located inside the garage. Laundry detergents and cleaning supplies were observed in garage away from residents.
Living/Family room:
There was a living/family room with furniture for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in each resident rooms and hygiene supplies will be stored inside the garage
Yards/Outside:
Patio table, chairs and shade were observed in the backyard. There was a gate on the South side and North side of the property with a self-latching door. All outdoor pathways were free of obstructions. LPA observed a spa with secured cover however it was not on the facility sketch.
Emergency Phone Numbers, and Exit Plan:
Facility sketch and Let-Us-No poster were observed posted in the main hallway. Exit plans observed at exits.

(Continued on Page 3)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

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: BLISSFUL CANYON HOMECARE 3	FACILITY NUMBER: 331881586
	VISIT DATE: 07/08/2024

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General items:
One (1) fire extinguishers were charged and located in the kitchen. Six (6) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked medicine cabinet. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply was observed however the required 72-hour emergency food supply was not discernible from the regular food supply. Component III will be completed on July 25, 2024 at Riverside RO.

Pre-Licensing is incomplete and the following corrections to be resolved by 7/15/2024:
obtain a separate 72-hour emergency food supply
obtain and post visiting policy
obtain and post Obudsman Poster
obtain and post Discrimination notice
obtain PPE supplies
obtain a boxspring for resident room #4
obtain chairs for rooms #2, #3, #4
post emergency telephone numbers
submit facility sketch to CAB with update for backyard that includes spa & fire pit
submit updated dementia care plan to CAB to include spa

An exit interview was conducted with Rosalinda Orleans and a copy of this report was given.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

LIC809 (FAS) - (06/04)

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