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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003601
Report Date: 02/28/2024
Date Signed: 02/28/2024 02:33:17 PM


Document Has Been Signed on 02/28/2024 02:33 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:LIDIA'S BLESSED HOMEFACILITY NUMBER:
507003601
ADMINISTRATOR:HIRISCAU, LIDIAFACILITY TYPE:
740
ADDRESS:3209 HUMMINGBIRD LANETELEPHONE:
(209) 575-3604
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 6DATE:
02/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lidia HiriscauTIME COMPLETED:
02:30 PM
NARRATIVE
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On 10/28/24 a meeting was held via Microsoft Teams to deliver findings related to complaint investigation. Present in the meeting were Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA) Maja Jensen and Licensee Lidia Hiriscau.

During the course of the investigation for compliant control number 27-AS-20230921092607, it was learned that the Licensee was designated as the financial Power of Attorney (POA) for resident 1.

The Department conducted interviews with Resident 1 and the Licensee who both confirmed that the Licensee took over as R1's POA. The Department also reviewed a notarized document dated 9/23/23 showing the Licensee as R1's POA.

Deficiencies are being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report was sent by email for electronic signature. Appeal rights and an LIC 811 was also sent by email to the Licensee.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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Document Has Been Signed on 02/28/2024 02:33 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LIDIA'S BLESSED HOME
FACILITY NUMBER: 507003601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/29/2024
Section Cited
CCR
87217(d)(2)

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Safeguards for Resident Cash, Personal Property, and Valuables...no licensee or employee of a facility shall:
...accept any general or special power of attorney for any such person. This requirement was not met as evidenced by:

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 Licensee will email an attestation that the regulation has been read, understood and will be complied to maja.jensen@dss.ca.gov by POC due date and will send proof that she has been removed as POA by 3/6/24.
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Based on the Department's review of documentation appointing the Licensee as R1's POA. This poses an immediate risk to the health, safety and personal rights of residents in care.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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