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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005548
Report Date: 11/08/2021
Date Signed: 11/08/2021 02:09:28 PM

Document Has Been Signed on 11/08/2021 02:09 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BLEVINS HOMEFACILITY NUMBER:
507005548
ADMINISTRATOR:CASEY BLEVINSFACILITY TYPE:
735
ADDRESS:3901 SWEEPSTAKES DRIVETELEPHONE:
(209) 863-9905
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 4CENSUS: 4DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Keisha JonesTIME COMPLETED:
02:20 PM
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On 11/8/2021 at 12:30pm Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual inspection. LPA contacted Licensee prior to today's inspection who confirmed no staff or residents have tested positive or shown symptoms within the past 10 days. LPA met with Designated Staff (S1) and was allowed entry into the facility that is licensed to serve a total capacity of 4, today's census is 4. Three of three staff observed on site with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 4/11/2023.

LPA interacted with a random number of residents during this visit and observed residents engaged in activities and crafts. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, garage, restrooms, bedrooms, and common living areas to be clean and in good repair. LPA observed switch cover removed from electrical outlet in restroom and hose uncoiled on back patio walkway. The temperature inside the facility was measured at 69*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 119*F within regulatory range of is not less than 105*F and not more than 120*F. LPA observed the centrally stored medications, toxins and knives to be locked inaccessible to residents. LPA observed medications administered on today's date. The first aid kit was observed in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, tweezers, scissors, thermometers, and Antiseptic solution.

Continued on 809 C.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BLEVINS HOME
FACILITY NUMBER: 507005548
VISIT DATE: 11/08/2021
NARRATIVE
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 Continued from 809.

Facility handles P & I monies, LPA observed the log is maintained correctly and there is no commingling of funds. LPA observed the facility conducts fire drills documented monthly.

LPA observed fire extinguisher last inspected on 11/5/2020, smoke and carbon monoxide detectors, central heating and air in the facility. Licensee contacted and confirmed no recent fire inspection completed. S1 left message to coordinate scheduling during today's visit. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed COVID precautions signs posted, restrooms stocked with hand soap, hand washing signs, and paper towels posted but not touchless covered trash cans. LPA observed 30 day supply of PPE stored is stored.

The facility has an approved Mitigation Plan.

Upon a file review the following items were discussed to be submitted to LPA by 11/20/2021:
Designation of Administrative Responsibility LIC308
Qualifications of Administrator
Personnel Report LIC500
Emergency Disaster Plan LIC610D
Surety Bond LIC402
Affidavit Regarding Cash Resources LIC400

Per California Code of Regulations (CCRs) - Title 22, the following deficiencies are being cited on the attached 809D during this visit. A copy of their rights (LIC9058) provided and a signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2021 02:09 PM - It Cannot Be Edited


Created By: Ashley Boothe On 11/08/2021 at 01:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BLEVINS HOME
FACILITY NUMBER: 507005548

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited

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 Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidence by:
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Based on observation, interview and record review the licensee did not comply with the section cited above in that LPA and S1 observed fire extinguishers last service was on 11/4/2020 which poses an immediate health, safety, and personal rights risk to 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:Liza King
LICENSING EVALUATOR NAME:Ashley Boothe
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021


LIC809 (FAS) - (06/04)
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