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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005903
Report Date: 03/14/2022
Date Signed: 03/14/2022 11:26:01 AM


Document Has Been Signed on 03/14/2022 11:26 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:BLESSED HOME FOR SENIORS INCFACILITY NUMBER:
347005903
ADMINISTRATOR:MERCIDITAS GALITOFACILITY TYPE:
740
ADDRESS:7619 KILLDEER WAYTELEPHONE:
(916) 896-0824
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 4DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mercidatas Galito - AdministratorTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection today, LPA met with Administrator, Merceditas Galito (Certificate #: 6002571740 expires 06/28/2023). There are currently four residents who reside at this facility. This facility has a hospice waiver for 2 residents and currently one resident is receiving hospice care.

LPA inspected the interior and the exterior of the facility including the common living spaces, Five resident bedrooms and three bathrooms, kitchen, and staff room. Bathrooms and bedrooms were clean and in good repair. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for two day perishable and seven day nonperishable. Fire alarms were checked and found to be in working order. Fire Extinguishers expire May 11, 2022. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed four of four resident records and three staff records. LPA reviewed medications of three residents comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. Liability insurance for the facility is current.

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 6, no deficiencies are being cited during this visit.


Exit Interview conducted and copy provided to Administrator.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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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