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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700343
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:16:33 PM


Document Has Been Signed on 09/10/2024 02:16 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:BLESSED HOME FOR SENIORS IIFACILITY NUMBER:
342700343
ADMINISTRATOR:GATCHALIAN, M AURORAFACILITY TYPE:
740
ADDRESS:9961 DOVE SHELL WAYTELEPHONE:
(916) 685-4334
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 6DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Aurora GatchalianTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio met with facility staff, and explained the purpose of the visit. LPA was later met by Administrator Aurora Gatchalian.

LPA Valerio and facility staff Mika toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed 6 residents bedrooms, which were observed to be clean, free from odors, and fully furnished. Resident bathrooms were equipped with skid mats, hand rails, paper towels, toilet paper, hygiene supplies, and a trash can. Hot water was measured within regulatory range. Common areas, such as the kitchen, dinning room, living room, and exterior areas, were observed to be clean and free from debris. No emergency exits were obstructed. The facility was observed to meet food requirements in addition to an emergency supply of food. The facility temperature was observed to be 75 degrees F. Fire extinguisher, carbon monoxide detectors, and door alarm systems were observed to be in working condition. Residents were observed having a family visit, reading a book, watching television, or taking a nap. Staff were observed cooking, cleaning, and assisting with resident ADLs.

LPA Valerio reviewed two (2) staff files, which were complete with required annual training. Three (3) residents files were observed to be updated with annual documentation and assessments.

LPA Valerio requested the following annual documentation be sent to LPA Valerio: LIC 500, LIC 308, LIC 610D, copy of Liability insurance.

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited today. An exit interview was held, and a copy of the report was provided to Administrator Aurora.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
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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