342700343-7-9-2021-27-AS-TTRG-C4RTWK-20210709150540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700343
Report Date: 07/09/2021
Date Signed: 07/09/2021 03:05:56 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 II		FACILITY NUMBER:	342700343
ADMINISTRATOR:	GATCHALIAN, M AURORA		FACILITY TYPE:	740
ADDRESS:	9961 DOVE SHELL WAY		TELEPHONE:	(916) 657-6647
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 6	DATE:	07/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Aurora Gatchalian, Administrator		TIME COMPLETED:	03:30 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) Tung Truong arrived at this facility unannounced on 07/09/2021 at 1:50pm to conduct an annual inspection visit. LPA met with administrator Aurora Gatchalian and explained the purpose of the visit. Administrator holds current certification #6005801740 and expires on 7/26/2021. The facility is licensed for 6 non-ambulatory residents, which 1 may be bedridden in room #1 only. There are currently 6 residents of which 1 is bedridden. LPA toured the facility with administrator Aurora Gatchalian on 07/09/2021 at 2:10pm. LPA inspected the physical plant including but not limited to the common areas, kitchen, dining area, resident bedrooms; resident bathrooms, garage, 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 110.8 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. 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: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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 II	FACILITY NUMBER: 342700343
	VISIT DATE: 07/09/2021

NARRATIVE

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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.

Administrator was informed to send a copy of the following updated documents to Licensing Office with 15 days: (1) LIC 308 Designation of Administrative Responsibility; (2) LIC 500 Personnel Report; (3) Copy of Administrator Certificate; (4) LIC 610 Emergency Disaster Plan; (5) Proof of Current Liability Insurance

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

Exit interview conducted and copy of report provided

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

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