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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005548
Report Date: 03/25/2024
Date Signed: 04/02/2024 03:58:14 PM

Document Has Been Signed on 04/02/2024 03:58 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:BLEVINS HOMEFACILITY NUMBER:
507005548
ADMINISTRATOR:CASEY BLEVINSFACILITY TYPE:
735
ADDRESS:3901 SWEEPSTAKES DRIVETELEPHONE:
(209) 863-9905
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 4CENSUS: 4DATE:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Casey Blevins, Kesha Jones, Betty MitchellTIME COMPLETED:
02:00 PM
NARRATIVE
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Unannounced Annual visit made out to this facility on 03/25/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Betty Mitchell, who was briefly interviewed. This LPA requested that the facility caregiver go ahead and contact the facility designated Administrator, Casey Blevins, to inform him that CCL was present at this time. Assistant Administrator, Kesha Jones, arrived later to this facility while this LPA was conducting this annual visit.
This facility was vendorized through the regional center, Valley Mountain Regional Center, to accept and retain Level 3 regional center clients at this time.
Current census was 4, of which, one resident was out at their respectable day program at this time.
It was learned that there weren't any residents under the care of hospice at this time.
It was learned that there weren't any residents diagnosed with dementia at this time.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Casey Blevins. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date of 04/12/2025 with certificate # 7003004735.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet and supplies, located in the entry way closet, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility caregiver at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
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)
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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: BLEVINS HOME
FACILITY NUMBER: 507005548
VISIT DATE: 03/25/2024
NARRATIVE
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Linen closets were observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
Laundry area, located in the garage area, was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers (2), located in the kitchen and hallway, were observed to have been annually inspected on 10/16/2023 by the local fire extinguisher company, ARF Fire Inc, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (4) facility resident records was conducted and noted on the following LIC 858 form.
A review of (3) facility staff records was conducted and noted on the following LIC 859 form.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

A civil penalty of $500 was assessed during todays annual visit on the following LIC 421IM for violation of the fire clearance. This facility had a nonambulatory resident in care while this facility was fire cleared to only accept and retain ambulatory only residents.

Appeal Rights were printed and a copy was given to the facility designated Assistant Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
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)
Page: 2 of 4
Document Has Been Signed on 04/02/2024 03:58 PM - It Cannot Be Edited


Created By: Charlie Yang On 03/25/2024 at 01:56 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLEVINS HOME
FACILITY NUMBER: 507005548

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) 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 evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [4] facility resident Physician's Report (LIC 602) revealed that a current resident was deemed to be non ambulatory and this facility is only fire cleared for ambulatory only residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Facility representative stated that a medical appointment will be scheduled in order to address this change in ambulatory status and notify the service coordinator for possible relocation. A statement of correction, along with updated LIC 602 if updated to address a possible relocation, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/02/2024 03:58 PM - It Cannot Be Edited


Created By: Charlie Yang On 03/25/2024 at 01:56 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLEVINS HOME
FACILITY NUMBER: 507005548

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that holes were observed in a residents closet area and room. Missing baseboards were observed as well. Window screens were observed to be missing while some had holes, tears, and rips in them which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2024
Plan of Correction
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Facility Assistant Administrator stated that the baseboards will be replaced. All holes will be patched and fixed in the residents closet area and room. Facility window screens will be repaired/replaced to address any tears, rips, and holes. A statement of correction, along with receipts for services rendered and photos, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024


LIC809 (FAS) - (06/04)
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