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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005548
Report Date: 03/06/2025
Date Signed: 03/11/2025 10:41:47 AM

Document Has Been Signed on 03/11/2025 10:41 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:BLEVINS HOMEFACILITY NUMBER:
507005548
ADMINISTRATOR/
DIRECTOR:		CASEY BLEVINSFACILITY TYPE:
735
ADDRESS:3901 SWEEPSTAKES DRIVETELEPHONE:
(209) 863-9905
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 4CENSUS: 4DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Betty Mitchell, Keisha Jones, and Casey BlevinsTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 03/06/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Betty Mitchell, who was briefly interviewed at this time.
This LPA requested that she go ahead and contact the facility designated Administrator, Casey Blevins, to inform him that CCL was present at this time. The facility designated Administrator arrived later to this facility while this LPA was conducting this annual visit.
Current census was (4) residents, of which, (2) residents were out of the facility at this time attending their respective day programs.
It was learned that this facility was vendorized through Valley Mountain Regional Center (VMRC) to be able to accept and retain Level 3 residents at any given time.
Tour of the facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed to make sure that this facility had a sufficient supply of plates, dinnerware, and flatware in order to be able to meet the needs of the residents at this time.
Food storage units were observed to be present and in functional order at this time.
A review of the 2-day perishable and 7-day non-perishable food quantities was conducted and observed to be in compliance at this time.
Additional food storage units were observed to be present in other areas of this facility and found to be in compliance at this time.
Medication cabinet, located in the facility entry closet, was toured. Medications were observed to be stored and made inaccessible to the residents at this time. A review of the facility Medication Administration Record was conducted at this time.
First aid kit was observed to be present and did contain all of the required components at this time.
Laundry area stationed in the garage was toured. Cabinets housing detergents, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been recently checked by the local fire extinguisher company, ARF Fire Extinguisher Co, on 10/25/2024 and in compliance at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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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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: 03/06/2025
NARRATIVE
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A tour of the dining area, living area, and all other areas designated for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time in compliance.
A tour of the resident restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the resident at this time in compliance.
Hot water temperatures were taken to make sure that the hot water being dispensed for resident use were within the allowed range of 105-120 degrees at all times.
Administrator Certificate for the facility designated Administrator, Casey Blevins, was observed to have the following certificate number #7003004735 set to expire on 04/12/2025 at this time. It was learned that forms and documents are in the process of being completed for the renewal.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gate, and all other exits was conducted at this time.
A review of (3) facility staff files was conducted and noted on the following LIC 859.
A review of (4) facility resident files was conducted and noted on the following LIC 858.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

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.

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

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/11/2025 10:41 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/06/2025 at 12:33 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: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

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 there was not a sufficient supply of 7-days worth of non perishable food items which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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The facility representative stated additional food items will be purchased to make sure that this facility maintained 7-days worth of non perishable quantities at all times. A statement of correction, along with copies of the receipt for the updated food items purchased, 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: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/11/2025 10:41 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/06/2025 at 12:33 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: 03/06/2025

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 the side gate was in need of repair in order to close/latch properly. In addition, the other side gate needed to be repaired with the side yard which needed to be cleared of branches and leaves to make it clear which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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The facility designated representative stated that the side gate will be repaired/replaced to close and latch properly at all times. In addition, the other side gate will be latched or secured properly to close and latch as well. The side yard will be cleared of all branches and leaves to make this area clear at all times. A statement of correction, along with photos of the updated items, 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: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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