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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005548
Report Date: 03/16/2022
Date Signed: 03/17/2022 07:07:12 AM

Document Has Been Signed on 03/17/2022 07:07 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
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:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Craig Blevins, AdminstratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the care home to conduct an unannounced Annual inspection on this date. The Administrator for the facility, Craig Blevins, was informed of the purpose of the visit and arrived during the inspection. Staff were able to assist with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. The facility is Regional Center vendorized home. The facility has 4 clients and 3 bedrooms and two bathrooms. The three clients at the home and engaged in activities.

LPAs toured the facility and reviewed the Mitigation Plan as well as discussing Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures during the Post-Licensing Inspection. Smoke alarms were tested and were operable. Fire extinguishers were serviced in November 2001. Toxins and medications were locked and inaccessible to clients in care. Food supply determined to be adequate. Inside and outdoor exits were unlocked and accessible. Water temperature was measured at 119.0 degrees F.

LPA observed the following posted in the facility: COVID requirements, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. LIC 500, LIC 308, and LIC 309 were requested to be submitted to Licensing within 30 days.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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: 03/16/2022
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Administrator's Certifcation for Mr. Blevins # 6010821735 expires 4/11/23,

Exit interview held with Administrator, no deficiencies were issued and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
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