342700307-6-23-2021-27-AS-TTRG-C49TH2-20210623144401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700307
Report Date: 06/23/2021
Date Signed: 06/23/2021 02:44:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	BLESSED HOME FOR SENIORS III		FACILITY NUMBER:	342700307
ADMINISTRATOR:	GATCHALIAN, AIDA		FACILITY TYPE:	740
ADDRESS:	10070 KNOTTS DR		TELEPHONE:	(916) 895-2890
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 5	DATE:	06/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Aurora Gatchalian, Administrator		TIME COMPLETED:	03:00 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) Tung Truong arrived at this facility unannounced on 06/23/2021 at 1:15 PM to conduct an annual inspection visit. LPA met with administrator Aurora Gatchalian and explained the purpose of the visit. Administrator Aida Gatchalian holds current certification #6008136740 and expires on 10/1/2021. Administrator Aurora Gatchalian hold current certification #6005801740 and expires on 7/26/2021. The facility is licensed for 6 non-ambulatory residents, of which 1 maybe bedridden in room #6 only. There are currently 5 residents of which 1 is bedridden. LPA toured the facility with administrator Aurora Gatchalian on 06/23/2021 at 1:25 PM. LPA inspected the physical plant including but not limited to the kitchen, dining area, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained and the hot water temperature was observed to be 108.3 degrees Fahrenheit. LPA observed there to be a sufficient amount of perishable and non-perishable food supply on hand. LPA observed knives and toxins to be locked away and inaccessible to residents. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. The facility was in compliance. LPA also conducted the infection control domain tool. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BLESSED HOME FOR SENIORS III	FACILITY NUMBER: 342700307
	VISIT DATE: 06/23/2021

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The facility mitigation plan was submitted to CCLD, and it was approved on 3/28/2021. Facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

The following documents were requested:

-Personnel Report (LIC 500)
-Emergency Disaster Plan
-Designation of Administrative Responsibility. (LIC 308)

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

Exit interview was held and a report was given.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

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