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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530106
Report Date: 09/04/2025
Date Signed: 09/04/2025 10:32:24 AM

Document Has Been Signed on 09/04/2025 10:32 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BLESSIE HOMECAREFACILITY NUMBER:
365530106
ADMINISTRATOR/
DIRECTOR:		DOMINADOR P. BARTOLATA IIIFACILITY TYPE:
735
ADDRESS:7325 TANGELO AVENUETELEPHONE:
(909) 440-6644
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 3DATE:
09/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Facility Administrator Dominador Bartolata IIITIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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On 09/04/2025 at 08:40 AM, Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA Singh was greeted by staff Joey Magundayao Totto and gained access at the home. Facility Administrator Dominador Bartolata III was contacted, informed and arrived during the visit. LPA Singh explained the purpose of the visit to Facility Administrator Dominador Bartolata III.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is a level 4i and vendorized by Inland Regional Center (IRC). LPA completed a walk through 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), LPA observed two (2) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, lamps and sufficient lighting. LPA Singh inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 134 degrees Fahrenheit. deficiency will be issued. 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. LPA Singh observed night lights at the hallway leading to clients' shared bathrooms, no issues.

*** Continuation in LIC809C ***

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Beena Singh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BLESSIE HOMECARE
FACILITY NUMBER: 365530106
VISIT DATE: 09/04/2025
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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.

Food Service: LPA Singh observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks in garage in the cupboard. Dishes, cups, and utensils were stored properly in the kitchen.

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



Record Review: LPA reviewed three (3) client file for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPA observed files reviewed were complete. LPA audited two (2) client's medications and two (2) clients Personal and Incidental (P&I) and no issues observed.

LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, training, and health screenings with tuberculosis (TB) test result. LPA observed records reviewed were complete. Emergency Fire drill conducted on 07/02/2025 and Earthquake drill on 05/08/2025. Liability Insurance certificate valid through 11/21/2024-11/21/2025.

An exit interview was conducted where this report LIC809, LIC809C were discussed, and copies were provided to Facility Administrator Dominador Bartolata III

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Beena Singh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/04/2025 10:32 AM - It Cannot Be Edited


Created By: Beena Singh On 09/04/2025 at 10:10 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BLESSIE HOMECARE
FACILITY NUMBER: 365530106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not ensuring that faucets used by clients are delivering hot water temperature not more than 120 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
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Facility administrator adjusted the temperature of the hot water during the visit.
Type A
Section Cited
CCR
80088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs.

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 by not ensuring that hot water deliring water at 125 degrees or above shall be prominently identified by warning signs, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
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Fcaility administrator stated to place warning signs displayed over the faucets delivering hot water at 125 degrees or above and submit proof to LPA Singh by email 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.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Beena Singh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


LIC809 (FAS) - (06/04)
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