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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200543
Report Date: 09/01/2022
Date Signed: 09/01/2022 11:54:35 AM


Document Has Been Signed on 09/01/2022 11:54 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:A BLISSFUL RETREAT, LLCFACILITY NUMBER:
079200543
ADMINISTRATOR:OSMAN, SUMAIYAFACILITY TYPE:
740
ADDRESS:4200 COWELL ROADTELEPHONE:
(925) 726-8888
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 6DATE:
09/01/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Sumaiya Osman, AdministratorTIME COMPLETED:
12:20 PM
NARRATIVE
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This is an amendment to original LIC 809 dated 8/18/2022.

On 9/1/2022 at 9:45am LPAs C. Fowler and Paris Watson arrived unannounced to deliver this amended report. The report of 8/18/2022 was generated under this facility in error. That report was for sister facility A Blissful Retreat, LLC- Wilson a new annual was conducted for this facility on 9/1/2022.

Upon entry, LPAs observed screening station that contained hand sanitizer, masks and COVID signage. LPAs toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters.

During record review, LPA observed visitors log and temperature logs for residents or staff. LPA observed facility has a copy of Mitigation Plan.

The following deficiencies were observed during the visit:

-At 9:50 am, LPAs observed staff not fingerprint cleared and associated to the facility.
-At 10:07 am, LPAs observed a locked gate on the side yard.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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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Document Has Been Signed on 09/01/2022 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: A BLISSFUL RETREAT, LLC
FACILITY NUMBER: 079200543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2022
Section Cited

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(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:
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Based on record review,

the licensee did not comply with the section cited above by having staff that is not finger print cleared working at the facility which poses an immediate health and safety risk to persons in care.
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Type A
09/02/2022
Section Cited

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(a) All facilities shall maintain a fire clearance approved by the city, ... Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance ... protection services, or the State Fire Marshal:
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Based on record review,
the licensee did not comply with the section cited above by locking side gate which poses an immediate health and safety risk to persons 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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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