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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424584
Report Date: 07/03/2023
Date Signed: 07/03/2023 01:27:37 PM


Document Has Been Signed on 07/03/2023 01:27 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:BLESSED ELDER CARE, INC.FACILITY NUMBER:
336424584
ADMINISTRATOR:MAGDALINA GURAUFACILITY TYPE:
740
ADDRESS:5041 SIERRA ST.TELEPHONE:
(951) 588-6533
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:12CENSUS: 12DATE:
07/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator Magdalina GurauTIME COMPLETED:
01:30 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) Janette Romero conducted an unannounced annual required visit on 7/3/2023 at 10:45 a.m. LPA was granted entry by Caregiver Jenine Cummings who was informed of the purpose of the visit. During the visit, Administrators Magdalina Gurau and John Gurau arrived. At the time of the visit there was 11 residents and (2) staff present.

The facility is made up of a one-story home with 10 bedrooms, four (4) full bathrooms, four (4) half baths with an attached garage. There are no bodies of water on the premises. Nine (9) of the bedrooms are designated for residents and one (1) for live-in staff. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted staff and resident interviews. LPA observed the following:

Physical Plant: LPA toured the resident bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture in the home were observed in good repair along with outdoor furniture and shaded area for clients. Knives were observed to be locked and secured in a kitchen cabinet. Smoke alarms and carbon monoxide detector were operational. Resident restroom showers were equipped with a grab bar and non-slips mats. First aid kit was complete. The facility has clean towels, blankets, and linen, available in different colors for residents.

Continued on LIC809-C..

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
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 3


Document Has Been Signed on 07/03/2023 01:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: BLESSED ELDER CARE, INC.
FACILITY NUMBER: 336424584

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in by leaving Clorox Disinfecting Wipes accessible on the kitchen counter, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
1
2
3
4
Facility secured Clorox Disinfecting Wipes during the visit and agreed to provide proof of staff training regarding securing disinfectants and cleaning solutions, making the inaccessible to residents in care. Proof of correction to be submitted to CCLD by close of business on 7/7/2023.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above by transferring medications out of their original containers onto daily pill organizers for 11 residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
1
2
3
4
Facility agreed to maintain medications in their original containers and provide proof of staff training regarding centrally stored medication. Proof of correction to be submitted to CCLD by 7/7/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BLESSED ELDER CARE, INC.
FACILITY NUMBER: 336424584
VISIT DATE: 07/03/2023
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
Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility had sufficient non-perishable foods, but had a low supply of perishable foods for 11 residents in care. During the visit, Administrator John Gurau went to Smart and Final and purchased perishable food items for the residents.

Care & Supervision/Administration: Adequate staff are present for the supervision of residents. Staff present have proper clearance and association to the facility. Facility sketch, exit routes, personal rights procedures and emergency phone numbers were posted throughout the facility.

Centrally Stored Medications: LPA observed medication transferred from their original containers and placed onto daily pill organizer containers for 11 residents in care.

Deficiencies: LPA observed unsecured Clorox Wipes on kitchen countertop. LPA observed medication transferred to daily pill organizer containers for 11 residents. Daily pill organizers were only labeled with the residents’ name.



This report was discussed with Administrator Magdalina Gurau and a copy was provided to the facility along with an LIC809-D and Appeal Rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3