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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426277
Report Date: 01/24/2025
Date Signed: 01/24/2025 11:47:54 AM

Document Has Been Signed on 01/24/2025 11:47 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:BLISSFUL CANYON HOMECAREFACILITY NUMBER:
336426277
ADMINISTRATOR/
DIRECTOR:		ROSALINDA ORLEANSFACILITY TYPE:
740
ADDRESS:1770 CENTURY AVE.TELEPHONE:
(951) 789-0170
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Rosalinda Orleans, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card.

Resident record review began- Five (5) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms-2 missing, identification and emergency information, appraisal needs and service plans-1 missing, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is is not meeting documentation requirements.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 117.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location.



Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. Foods are dated to assure safety. Food prep areas are clean and organized.

LPA began review of employee records- Five (5) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current.
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Jazmond D HarrisTELEPHONE: (951) 248-0318
Yolanda DelgadoTELEPHONE: (951) 203-2990
DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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
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
FACILITY NUMBER: 336426277
VISIT DATE: 01/24/2025
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(Continued on from Page 1)

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure was changed in 2022 and LIC809 dated 2/15/2022 noted that facility is under renovations however no updated floor plan and no updated STD. 500 (family/living room was renovated to rooms for residents) was observed in facility's file. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 01/04/2025. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 11/20/2024. There are no firearms stored at the facility and there is a pool with a black mesh barrier fencing surrounding the exterior of the pool.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, there are two (2) deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

This report, LIC809D, Appeal Rights was reviewed with and a copy provided to the facility representative at the time of the exit interview.

LPA has requested the Licensee to complete and submit LIC200 and updated floor plan to CCLD by 1/31/2025
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 01/24/2025 11:47 AM - 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: BLISSFUL CANYON HOMECARE
FACILITY NUMBER: 336426277

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in renovations were conducted in 2022, no updated facility floor plan and STD.500 was not observed in facility file, Licensee could not provide the requested documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee will submit LIC200 and updated facility floor plan to CCLD by POC due date.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in Resident #1 did not have a preapprasial observed in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee will email a copy of R1's preappraisal to LPA by POC due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jazmond D HarrisTELEPHONE: (951) 248-0318
Yolanda DelgadoTELEPHONE: (951) 203-2990

DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025

LIC809 (FAS) - (06/04)
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