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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202920
Report Date: 02/13/2025
Date Signed: 02/21/2025 03:13:29 PM

Document Has Been Signed on 02/21/2025 03:13 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BLISS FIVE RESIDENTIAL CARE HOME INC.FACILITY NUMBER:
435202920
ADMINISTRATOR/
DIRECTOR:
SANTOS, MICHELLE SFACILITY TYPE:
735
ADDRESS:978 SOUTH SECOND STREETTELEPHONE:
(408) 469-7154
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 6CENSUS: 4DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Michelle SantosTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Michelle Santos.

During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen and food storage areas. LPA observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA reviewed the first aid kit and found it to be complete.

LPA toured three out of three resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA Marrufo tested the smoke detectors in each bedroom and in the hallway and each smoke detector functioned properly when tested. LPA tested the hallway carbon monoxide detector and it functioned properly when tested.

LPA toured two out of two bathrooms. Each bathroom had working lights and available soap and paper towels. The showers had anti-slip mats and shower chairs. The water in the bathroom sinks had temperatures of 118 F and 119 F.

LPA toured the outside area and found the outdoor exit to be clear of obstructions.

LPA reviewed four out of four resident records, including Centrally Stored Medication and Destruction Records and Personal and Incidental Money Logs, and found them to be complete. LPA reviewed five staff records and found them to be complete. The Emergency Disaster Drill Log indicates the last drill was conducted on 12/03/2024.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Michelle Santos and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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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