342700343-8-8-2023-27-AS-TTRG-CUHQBE-20230808120126

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700343
Report Date: 08/08/2023
Date Signed: 08/08/2023 12:01:30 PM

Document Has Been Signed on 08/08/2023 12:01 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
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) 685-4334
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 5	DATE:	08/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Aurora Gatchalian		TIME COMPLETED:	12:30 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	On 8/8/2023, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Upon LPAs arrival, Caregiver Eduardo Torrecarion was present at facility and contacted Administrator Aurora Gatchalian who arrived a bit later. LPA met with Administrator Aurora Gatchalian and explained the purpose of the visit. Administrator holds certification # 6005801740 and expires on 7/26/2023. Renewal application has been submitted and currently pending. The facility is licensed for 6 non-ambulatory residents, which 1 may be bedridden in room #1 only. There are currently 5 residents who reside at this facility. LPA toured the facility with administrator Aurora Gatchalian on 8/8/2023 at 9:45 am. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents in care. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 109.2F which was within the required range of 105-120F. The temperature inside the facility measured at 72F which was within the required range of 68-85F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. Proof of current liability insurance was observed. Report 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: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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: 08/08/2023

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LPA requested resident and staff files for review. LPA reviewed (5) resident files and (2) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following forms and documents were requested:
(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 there were no deficiencies cited during today's inspection. An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC809 (FAS) - (06/04)

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