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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700449
Report Date: 05/06/2022
Date Signed: 05/06/2022 02:01:29 PM


Document Has Been Signed on 05/06/2022 02:01 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:GREENHAVEN BLISSFUL HOMEFACILITY NUMBER:
342700449
ADMINISTRATOR:TORRES, CHRISTINEFACILITY TYPE:
740
ADDRESS:6200 FENNWOOD CTTELEPHONE:
(916) 753-7564
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Judith Lanuza, CaregiverTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 5/6/22 at 1:20PM to conduct an annual inspection visit. LPA met with Judith Lanuza, Caregiver and explained the purpose of the visit. Caregiver contacted Administrator regarding todays visit. Hospice approved for 2 residents. There are 0 residents receiving hospice services during this visit. Licensing fees are current. Administrator certificate expires 10/23/22 for Christine Torres.

The facility is licensed for a capacity of 6 residents. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents during this visit. LPA observed 2-day perishables and 7-day non-perishables.

The temperature inside the facility was observed to be at 78*F which is within the required range of 68-85*F. The hot water temperature was measured at 109.4*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, pull alarm system, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), current Liability Insurance, Personnel Report (LIC500), Administrator Certificate-Updated

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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