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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700631
Report Date: 09/11/2024
Date Signed: 09/11/2024 11:36:38 AM


Document Has Been Signed on 09/11/2024 11:36 AM - 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 IVFACILITY NUMBER:
342700631
ADMINISTRATOR:GATCHALIAN, AIDAFACILITY TYPE:
740
ADDRESS:9771 ROEDELL WAYTELEPHONE:
(916) 793-9941
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Aida GatchalianTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/11/24 at 8:30AM. LPA met with Aida Gatchalian and stated the purpose of todays visit. Administrator certificate expires 10/2/25.

The facility is licensed for a capacity of 6 non-ambulatory residents of which 1 maybe bedridden in room #2. Hospice Waiver for 4. There are 0 bedridden and 1 hospice resident at this time.

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 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 110.0*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, 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.

LPA reviewed 2 staff and 2 resident files during this visit.

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: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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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