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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701304
Report Date: 11/02/2023
Date Signed: 11/02/2023 12:40:29 PM


Document Has Been Signed on 11/02/2023 12:40 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:A PLACE OF BLISSFACILITY NUMBER:
392701304
ADMINISTRATOR:IKISEH, CHUKWUDIFACILITY TYPE:
740
ADDRESS:10440 GRASS VALLEY CTTELEPHONE:
(209) 500-0990
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:6CENSUS: 0DATE:
11/02/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:IKISEH, CHUKWUDITIME COMPLETED:
12:45 PM
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On 10/26/2023, Licensing Program Analyst (LPA) Kesha Lewis arrived announced to conduct a Pre-Licensing visit. LPA was greeted by applicants, and explained the purpose of the visit. The purpose of this visit was to conduct a Pre-Licensing Visit. This facility will be licensed to hold 6 residents, of which 6 may be non-ambulatory, and a Hospice wavier for two (2).

A tour of the facility was conducted. Smoke detectors and carbon monoxide detectors were tested and are in good repair.

A tour of the kitchen area was toured. A review of food supply was conducted to ensure a 2 day perishable and 7 day non-perishable food supply was available. This facility will have a locked medication cabinet located in entrance hallway. A first aid kit was observed and had all the required components. Fire extinguisher was located in kitchen and was serviced on 06/23/2023 by the local fire company.
A tour of the family room was conducted. Furniture and furnishings were observed to be in good repair.
A tour of the backyard was conducted with no hazards present. Perimeter gate was observed to be in good repair.
A tour of garage was conducted. A washer and dryer was identified. in the laundry room Detergent, toxins and other cleaning supplies were observed to be locked and made inaccessible.
A tour of the resident bedrooms were conducted. Furniture and furnishing were observed to meet the residents needs.
A linen closet was located in hallway and was observed to have a sufficient amount of linen to meet the residents needs at this time.
Hot water temperature was taken to ensure that it was in within 105-120 degrees.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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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