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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003601
Report Date: 04/23/2025
Date Signed: 04/23/2025 11:19:55 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/23/2025 11:19 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LIDIA'S BLESSED HOMEFACILITY NUMBER:
507003601
ADMINISTRATOR/
DIRECTOR:		HIRISCAU, LIDIAFACILITY TYPE:
740
ADDRESS:3209 HUMMINGBIRD LANETELEPHONE:
(209) 575-3604
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
04/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Beniamin Siriciurdas, CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct an annual inspection. LPA Campbell met with Beniamin Siriciurdas, Caregiver and Lidia Hiriscau, Administrator and explained the purpose of the visit.

As observed by LPA Campbell, there are five clients residing in the facility.  All rooms have the required accessories of bed, chest of drawers, closet, night stand and lamp and chair. LPA Campbell toured the outside area. Vegetation was manicured and the patio area was furnished with dining furniture and a barbecue grill. Lemon and other trees provided shade. Pathways and exits were free of obstruction and accessible for non-ambulatory residents.

LPA Campbell toured the facility and inspected common areas, the kitchen, bedrooms and bathrooms to ensure there are no safety hazards for residents. The temperature for the facility freezer was -2 degrees Fahrenheit (F) and the refrigerator temperature was set at 37 degrees F. The facility temperature was 72 degrees F, which is within the required range of 68 and 85 degrees. The facility's water temperature was measured at 110 degrees F, which is within the required range of 105 and 120 degrees F.
Lisa RiosTELEPHONE: (916) 969-9685
Renee CampbellTELEPHONE: (916) 206-6380
DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
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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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LIDIA'S BLESSED HOME
FACILITY NUMBER: 507003601
VISIT DATE: 04/23/2025
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Of the five residents present in the facility, LPA Campbell reviewed four resident files. One file did not have a record of TB results, past or present. Of the four staff working in the facility, four of their files were reviewed and found to be complete. LPA Campbell consulted with the Administrator about putting their hire dates below the staff names on the front to make the information easier to find.

LPA Campbell observed first aid supplies, fully-charged and up-to-date fire extinguishers that were last inspected on 03/24/2025, and working carbon monoxide/smoke detectors. LPA Campbell observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable foods. LPA Campbell observed locked cabinets for the storage of medication. There were also locked storage areas for the storage of cleaning solutions in the laundry room and knives in the kitchen.

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8,
deficiencies were observed or cited and noted on LIC 809D. Note that failure to correct any deficiencies will result in additional civil  penalties.
An exit interview was conducted with Lidia Hiriscau, Administrator and a copy of this report was provided
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/23/2025 11:19 AM - 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: 04/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2025
Section Cited
CCR
87458(c)(1)

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(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the ... diagnosis or diagnoses and results of an examination for all of the following:
This requirement is not met as evidenced by:
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Licensee agrees to send LPA Campbell documentation of either a negative TB test or results from a chest x-ray indicating no evidence of active, communicable tuberculosis by POC due date. Information will be sent to renee.campbell@dss.ca.gov
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Based on record review, a resident did not receive tuberculosis test results during their medical assessment, nor did they receive results of a chest x-ray, which poses a potential health, safety, and/or personal rights risk.
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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.
Lisa RiosTELEPHONE: (916) 969-9685
Renee CampbellTELEPHONE: (916) 206-6380

DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025

LIC809 (FAS) - (06/04)
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