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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701304
Report Date: 02/07/2024
Date Signed: 02/07/2024 12:40:25 PM


Document Has Been Signed on 02/07/2024 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 3DATE:
02/07/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:IKISEH, CHUKWUDITIME COMPLETED:
12:45 PM
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On 2-7-2024, Licensing Program Analyst (LPA) Kesha Lewis arrived at this facility unannounced to conduct a post inspection visit. LPA met with the administrator and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is an RESIDENTIAL CARE for the ELDERLY with a current census of 3. Facility has 4 bedrooms and 3 bathrooms for resident use. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 2 ambulatory resident, 1 non ambulatory residents, 1 hospice, and 0 bedridden. The facility has an approved infection control plan in place.

Water temperature reads 110*F to 120*F in the bathroom. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 11-17-23. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and accessible to staff.

During this inspection 3 resident file and 1 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances.

LPA provided licensee with resources the LIC 858 and 859 checklists.

Exit interview and report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
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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