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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700631
Report Date: 09/24/2021
Date Signed: 09/24/2021 12:11:04 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 IVFACILITY NUMBER:
342700631
ADMINISTRATOR:GATCHALIAN, AIDAFACILITY TYPE:
740
ADDRESS:9771 ROEDELL WAYTELEPHONE:
(916) 897-8023
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 2DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Magnollia TolonTIME COMPLETED:
12:30 PM
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On 09/24/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced 1-year required infection control inspection. At approximately 11:40 AM, LPA met with Administrator Magnollia Tolon in the facility. LPA explained the purpose of the visit then was sanitized following the facility's entrance health and safety procedures. LPA also had his temperature checked and logged and then signed into the facility.

The Administrator stated the facility currently has one resident residing in the facility, with the second resident in the hospital due to an injury non-COVID-19 related, and with three new additional residents joining the facility at the end of this month.

At approximately 11:45 AM, LPA conducted a tour of the facility with the Administrator. The physical plant is consistent with the submitted facility sketch/floor plan and has the COVID-19 health and safety signage. There are no obstructions blocking indoor and outdoor passageways. No pools or bodies of water observed. The facility's kitchen is free of debris. Food and water supply were observed as sufficient. At 11:50 AM, LPA observed the facility's restrooms as clean and equipped with hand washing signage. The facility's backyard was free of debris.

The clients' bedrooms were inspected and all were private rooms with the required lighting and furniture. Facility was equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguisher as current. The facility's first aid kit included the required tweezers, scissors, and a thermometer. Cleaning solutions are stored and locked.

At approximately 11:55 AM, LPA completed the tour of the facility and began writing this report. LPA reviewed facility procedures for visitation entrance, temperature checks and logs, COVID-19 isolation, PPE, food and cleaning supply storage.

No deficiencies were cited today. Exit interview conducted with the Administrator. A copy of this report will be emailed to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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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