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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530106
Report Date: 08/03/2023
Date Signed: 08/03/2023 10:34:03 AM

Document Has Been Signed on 08/03/2023 10:34 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:
08/03/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator/Applicant Marivic Acero TIME COMPLETED:
10:45 AM
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On 08/03/2023 at 10:10 AM, Licensing Program Analyst (LPA) Melody Brown conducted an announced Prelicensing visit. This is an announced Pre-Licensing visit conducted with Administrator/Applicant Marivic Acero who assisted in the tour of inside and outside of the facility and the evaluation. LPA Melody Brown made a second (2nd) announced prelicensing visit this date. The follow up visit was made to confirm that all corrections have been made.

The following: Obtain 72-hour Emergency food for each clients/staff at the facility, Client Log in/Log Out and Visitor Log In/Log Out and Obtain Post Labor Laws were found to be corrected on this visit date, 08/03/2023.

Applicant/Administrator Acero reported that they already requested Ombudsman Poster and it will just be mailed to the home.

The facility was evaluated in accordance with the California Code of Regulation (CCR), Title 22 Chapter 6, Division 8. Based on the observations and evaluation of the facility this date, the facility’s ready for licensure.


Applicant/Administrator Marivic Acero will be notified once facility is licensed.

An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided with Applicant/ Administrator Marivic Acero.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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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