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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003601
Report Date: 03/25/2024
Date Signed: 03/25/2024 03:30:55 PM


Document Has Been Signed on 03/25/2024 03:30 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: 5DATE:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lidia HiriscauTIME COMPLETED:
03:45 PM
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On 3/25/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Licensee Lidia Hiriscau and explained the purpose of today's visit.

LPA Jensen toured the facility grounds and observed them to be well maintained. All paths were free of obstruction. There is outdoor furniture available and shaded areas for gathering. There are no bodies of water on the property. All window screens were observed to be in good repair. LPA Jensen reviewed the marketing materials which consist of a brochure and business card and determined them to be in compliance with the Health and Safety Code (HSC). The facility entrance has a wall mounted thermometer for screening if needed. The exits are clearly marked. LPA Jensen observed the Long Term Care Ombudsman Poster, Personal Rights and Fair Labor Practices poster. LPA Jensen did not observe any postings for See Something, Say Something and Resident Council. Technical assistance was provided. The facility carries current liability insurance through 2/19/2025 that is compliant. The Emergency Disaster Plan is posted and is compliant. The facility conducts fire drills that are logged and posted. The Administrator has submitted a certification renewal timely and is waiting for the renewal to be processed. All staff were determined to have criminal background clearance. The first aid kit was checked and determined to be complete. The carbon monoxide detector and smoke detector were observed to be in good working order. There is an emergency food supply and emergency lighting available.
LPA Jensen toured the facility and observed it to be sanitary and free of odor. There are currently 5 residents, one of which is on hospice care. The facility has 4 bedrooms and 4 bathrooms. Each bathroom is equipped with grab bars and non-skid flooring in the shower/bath area. The bathrooms have paper towel dispensers mounted to the walls. All garbage cans have tight fitting lids. There is adequate furnishing and lighting throughout. The facility maintains an adequate supply of linens. Medications, cleaning supplies and sharp objects were all observed to be locked and inaccessible to residents in care.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6


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: 03/25/2024
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LPA Jensen inspected the kitchen. The facility maintains a 2 day supply of perishable food and a 7 day supply of non-perishable food.

LPA Jensen interviewed 4 of 5 clients and 2 of 2 staff members present. All residents interviewed were satisfied with the care received. LPA Jensen reviewed 5 of 5 resident files. 3 of 5 resident files contained outdated Physician reports. 5 of 5 resident files were missing pages 2 and 3 of the Needs and Service Plans. 3 of 5 Needs and Service Plans were older than one year. Technical assistance is being provided. LPA Jensen reviewed 3 of 3 caregiver files. All caregiver files were observed to be complete and compliant. LPA Jensen provided technical assistance on refund upon death of a resident.

The facility sketch was observed to accurately reflect the facility layout and room usage. The fire extinguisher was last serviced January of 2024 and is in compliance. The water temperature in the bathroom was measured at 107 degrees which falls within the required range of 105-120 degrees Fahrenheit. The facility thermostat was set at 73 degrees which falls within the required range of 68-85 degrees Fahrenheit.

The facility was determined to be in substantial compliance. No deficiencies were issued as a result of this visit.

An exit interview was conducted and a copy of this report is being emailed to the Licensee.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC809 (FAS) - (06/04)
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