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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530106
Report Date: 07/26/2023
Date Signed: 07/27/2023 05:08:08 AM

Document Has Been Signed on 07/27/2023 05:08 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:BLESSIE HOMECAREFACILITY NUMBER:
365530106
ADMINISTRATOR:DOMINADOR P. BARTOLATA IIIFACILITY TYPE:
735
ADDRESS:7325 TANGELO AVENUETELEPHONE:
(909) 440-6644
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 0DATE:
07/26/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Administrator/Applicant Marivic AceroTIME COMPLETED:
04:57 PM
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On 07/26/2023 at 02:22 PM, Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPA met with Administrator/Applicant Marivic Acero. An initial application to operate an Adult Residential Facility was submitted to the Central Applications Bureau (CAB) on 02/23/2023 for a total capacity of four (4) Nonambulatory. Fire clearance was granted on 05/23/2023. LPA Brown observed the following:
Structure:
Facility was a one (1) story house with four (4) client bedrooms, two (2) client bathrooms, living room, dining area and kitchen. There was an attached two (2) car garage in the right side of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with one (1) central panel located in the hallway to control entire house.
Bedrooms:
Each client bedrooms accommodate any nonambulatory client. All client bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The (2) two client/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. LPA Brown tested the water temperatures in the clients' bathrooms. LPA Brown verified water temperature was measured at 113 degrees Fahrenheit.

***CONTINUED ON LIC 809-C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: BLESSIE HOMECARE
FACILITY NUMBER: 365530106
VISIT DATE: 07/26/2023
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***CONTINUED FROM LIC 809***
Additionally, LPA Brown observed facility not having Visitor Sign In/Sign Out Sheet and Client Sign In/Sign Out Sheet, upon entering facility. LPA Brown observed COVID signages throughout the facility, disposable towels in bathrooms for washing hands.

Pre-Licensing is incomplete and the following deficiencies to be resolved by 08/03/2023 at 10:00 AM:

· Obtain 72-hour Emergency food for each clients/staff at the facility


· Client Log in/Log Out and Visitor Log In/Log Out
  • Obtain Ombudsman Foster
  • Post Labor Laws

An exit interview was conducted, and a copy of this report, LIC809 was discussed and provided to Applicant/Administrator Marivic Acero.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: BLESSIE HOMECARE
FACILITY NUMBER: 365530106
VISIT DATE: 07/26/2023
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***CONTINUED FROM LIC 809***
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA Brown observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the garage. Laundry detergents and cleaning supplies were observed in the garage in a locked cabinet. Garage door is locked away from clients.
Living/Family room:
There was a living/family room with adequate seating for all clients and a working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the hallway of the residence.
Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle gate on right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted near the main entrance. There was Let-Us-No poster observed. but no Ombudsman poster and Labor Laws posted.
General items:
One (1) fire extinguishers was charged and located in the kitchen. Six (6) smoke detectors and one (1) carbon monoxide detector were tested and were observed to be in working order. Client records and staff records will be stored in a locked cabinet in the hallway. First Aid kit with required components, and locked area for medication storage was observed. LPA Brown observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 909-440-6644. There is enough Emergency water supply and 72-hour Emergency bag pack for clients observed but no required 72-hour emergency food supply for clients and staffs available at the facility. Component III was completed on this day as well.

***CONTINUED ON LIC 809-C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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