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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005903
Report Date: 04/06/2023
Date Signed: 04/06/2023 12:48:03 PM


Document Has Been Signed on 04/06/2023 12:48 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
SACRAMENTO AC/SC, 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: 5DATE:
04/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Merceditas GalitoTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Jason Lund arrived unannounced to conduct an annual inspection. LPAs Moleski and Lund met with administrator Merceditas Galito and explained the purpose of the visit.

LPAs Moleski and Lund requested two staff files for S1 and S2 and two resident files for R1 and R2. LPAs Moleski and Lund received a copy of Galito's administrator certificate, number 6002571740, expiry 06/28/23. LPAs Moleski and Lund interviewed two residents and one staff member.

LPAs Moleski and Lund toured the facility with administrator Galito. LPAs Moleski and Lund observed the kitchen, dining area, living area, resident bedrooms, resident bathrooms and outdoor areas. LPAs observed the required two-day supply of perishable food and seven-day supply of nonperishable food. LPAs observed smoke and carbon detectors, up-to-date fire extinguishers, and first aid kits with all required components. LPAs observed furniture and fixtures throughout the facility appeared sufficient to meet the needs of residents at this time.

LPA Moleski measured the water temperature in a resident bathroom. LPA Moleski and administrator Galito observed a reading of 135 degrees, which is outside the required range of 105 and 120 degrees. The air temperature in the facility was observed to be 77 degrees, which is within the required range of 68 and 85 degrees.

This facility is being cited per 22 CCR Section 87303(e)(2). An exit interview was conducted with administrator Galito. Appeal rights and a copy of this report was left with Galito.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/06/2023 12:48 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: BLESSED HOME FOR SENIORS INC
FACILITY NUMBER: 347005903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in a resident bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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Conduct staff training regarding weekly water temperature testing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
LIC809 (FAS) - (06/04)
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