336426277-1-23-2024-18-AS-JARA-CZS2FT-20240123162203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426277
Report Date: 01/23/2024
Date Signed: 01/23/2024 04:22:10 PM

Document Has Been Signed on 01/23/2024 04:22 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BLISSFUL CANYON HOMECARE		FACILITY NUMBER:	336426277
ADMINISTRATOR:	ROSALINDA ORLEANS		FACILITY TYPE:	740
ADDRESS:	1770 CENTURY AVE.		TELEPHONE:	(951) 789-0170
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92506
CAPACITY:	6	CENSUS: 6	DATE:	01/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Administrator, Rosalinda Orleans		TIME COMPLETED:	04:30 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) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Administrator, Rosalinda Orleans, who was informed of the purpose of the visit. At time of visit there were (6) clients and (3) staff present. The facility is a one story home with (5) bedrooms and (2) bathrooms with attached garage. The facility does have a pool with a surrounding locked gate. No fire arms are kept at the facility. The facility is a residential care facility for the elderly serving elderly ages 60 and above. LPA observed the following: Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file and staff training. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The carbon monoxide detector was tested and operational during the visit. 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 met the required food items, and provisions for modified diets.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BLISSFUL CANYON HOMECARE	FACILITY NUMBER: 336426277
	VISIT DATE: 01/23/2024

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Record Review and Resident/Staff Files: LPA reviewed staff files and training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork, except for (1) client file which did not have an updated LIC602. Technical note was documented and staff made arrangements to obtain a copy.

Health Related Services/ Incidental Medical Services: All client medication was locked in a hallway cabinet. LPA reviewed client medications and found that MARS and medication was accounted for and had required labeling.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on 12/26/2023 The documentation did not meet the department standards and technical note was documented.

No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was reviewed and provided to, Administrator, Rosalinda Orleans

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC809 (FAS) - (06/04)

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