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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530106
Report Date: 08/12/2024
Date Signed: 08/12/2024 01:26:17 PM


Document Has Been Signed on 08/12/2024 01:26 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
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: 1DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:John Cedric CaluagTIME COMPLETED:
01:30 PM
NARRATIVE
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On 08/12/2024 at 11:00 AM, Licensing Program Analysts (LPAs) Melody Brown and Raquel Hernandez conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPAs Brown and Hernandez were greeted by a staff and gained access at the home. Administrator Dominador Bartolata III was contacted and informed of the visit. LPAs Brown and Hernandez explained the purpose of the visit to staff John Cedric Caluag.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Brown and Hernandez completed a walkthrough of the facility, review of records, client's Personal and Incidental (P&I)and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown and Hernandez observed one (1) client during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPAs Brown and Hernandez inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, lamps and sufficient lighting. LPAs Brown and Hernandez inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 114 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Brown and Hernandez observed night lights at the hallway leading to clients' shared bathrooms. However, LPAs Brown and Hernandez observed no non-slip mat in client bathroom. Deficiency will be issued.
*** Continuation in LIC809C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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 6


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: 08/12/2024
NARRATIVE
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The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions. During the visit, LPA brown observed the side gate locked. Deficiency will be issued.

Food Service: LPAs Brown and Hernandez observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPAs Brown and Hernandez reviewed one (1) client file for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPAs Brown and Hernandez observed files reviewed were complete. LPAs Brown and Hernandez also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs Brown and Hernandez observed records reviewed were complete.

LPAs Brown and Hernandez audited one (1) client medications and no issues were observed. LPAs Brown and Hernandez audited one (1) client's Personal and Incidental (P&I) and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, LIC421IM, LIC9102 and Appeal Rights were discussed, and copies were provided to staff John Cedric Caluag.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/12/2024 01:26 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: BLESSIE HOMECARE
FACILITY NUMBER: 365530106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the observed one (1) sharp peeler found in the kitchen drawer is locked and not accessible to client in care
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Licensee stated to train all staff on CCR 80087(g) and submit proof to LPA Brown on Plan of Correction (POC) due date.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 08/12/2024 01:26 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: BLESSIE HOMECARE
FACILITY NUMBER: 365530106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the window screen is in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated to install new window screen and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80087(b)(1)
80087 Buildings and Grounds (b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there’s non-slip mat on client bathroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee stated to obtain/purchase non-slip mat and submit proof to LPA Brown on Plan of Correction (POC) due date.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 08/12/2024 01:26 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: BLESSIE HOMECARE
FACILITY NUMBER: 365530106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)(2)
80020 Fire Clearance (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. (2) Prior to the use of secured perimeters, an applicant or licensee for an Adult Residential Facility or Group Home shall meet the fire clearance approval requirements of Title 17, Division 2, Chapter 3, Subchapter 4, Article 12, Section 56072(d) and (h).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by locking the side gate of the facility that leads to the backyard and no fire clearance obtained for secured perimeters which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Licensee stated to train all staff on CCR 80020(a)(2) and submit proof to LPA Brown on Plan of Correction (POC) due date.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6