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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880981
Report Date: 12/08/2022
Date Signed: 12/08/2022 01:53:21 PM

Document Has Been Signed on 12/08/2022 01:53 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BLESSED DREAM HOMEFACILITY NUMBER:
361880981
ADMINISTRATOR:DINEROS, OLIVERFACILITY TYPE:
735
ADDRESS:13348 AVA LOMA WAYTELEPHONE:
(909) 996-2108
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 4DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Siegfria Villafranca, Staff MemberTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Amber Coleman made an unannounced visit to the Blessed Dream Home Facility to conduct an annual inspection with a focus on infection control. LPA was greeted and invited inside facility by staff member Siegfria Villafraca, (S1) LPA explained the purpose of the visit. S1 contacted Licensee, Oliver Dineros, who arrived later during the visit. At the request of S1, LPA signed in and recorded temperature. LPA observed COVID Station equipped with PPE, hand sanitizer and disinfectant. Facility was observed to be clean, free of debris and odorless. Staff was observed wearing proper PPE through out visit.

LPA and S1 walked through facility and backyard. Administrator reported no current cases of COVID in facility at this time. All staff and residents have been vaccinated. Proper signs and signs regarding infection control were observed throughout facility. The facility staff has a plan in place to manage Covid-19 symptoms, which includes staff monitoring residents regularly for any changes in condition, which and daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility staff are responsible for cleaning and disinfecting the highly touched surfaces during their shift. Resident charts all included the necessary emergency information. Bathrooms observed to contain adequate, soap and paper products.

LPA observed no health or safety concerns during walk through of facility. The client rooms contained adequate furniture and sufficient lighting. LPA observed the facility's supply of additional linens and extra hygiene items and paper supplies for the resident. Fire and carbon monoxide alarms were tested and proved functional. Fire extinguishers located throughout facility are all full and meet regulation. Medications are kept in a secure cabinet in the kitchen. Chemicals and sharp objects were observed in secure cabinet under the sink.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted. Exit interview was conducted and discussed with Licensee and a copy of this report was provided.


SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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