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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700631
Report Date: 09/20/2022
Date Signed: 09/20/2022 05:01:17 PM


Document Has Been Signed on 09/20/2022 05:01 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 IVFACILITY NUMBER:
342700631
ADMINISTRATOR:GATCHALIAN, AIDAFACILITY TYPE:
740
ADDRESS:9771 ROEDELL WAYTELEPHONE:
(916) 897-8023
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Aida Gatchalian TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year Required visit on this date. LPA explained the purpose of the visit and toured the facility with Administrator, Aida Gatchalian and Staff Mamagnolia Tolon. Upon entry LPA was screened for COVID symptoms, a sign in/sign out procedure was observed as well as facility staff wearing masks.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms of which 6 bedrooms are occupied by the residents and no bedroom is occupied by staff. All indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide alarms were in operating condition during visit. Fire extinguisher was last serviced on 09/09/2022. Emergency Disaster Plan was last posted on 06/28/2022. First aid kit was observed to be complete. Last Fire Drill occurred on March of 2022.
LPA reviewed staff record 3 out of 3 files. One staff member was found to have a positive TB test with no chest x-ray. All staff files TB results were verified and no other positive TB results were found. The facility has sufficient staffing to provide the services needed to meet the residents’ needs. All staff have criminal record clearance and are associated to the facility. All staff have current first aid training. The facility serves residents with dementia and staff have received the necessary training hours.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 ,and California Health and Safety Code. Failure to correct deficiencies may result in civil penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided.


SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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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Document Has Been Signed on 09/20/2022 05:01 PM - It Cannot Be Edited

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 IV
FACILITY NUMBER: 342700631

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited

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87411(f) Good physical health shall be verified by a health screening, including a chest x-ray .......Personnel with evidence of physical illness or emotional instability that poses a significant threat .......shall be relieved of their duties.
Based on record review
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The licensee did not ensure a that S1 was negative for TB for 1 of 6 staff members, which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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