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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700822
Report Date: 11/09/2023
Date Signed: 11/09/2023 04:34:21 PM


Document Has Been Signed on 11/09/2023 04:34 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
Lookup Error,
, CA



FACILITY NAME:BLISSFUL GARDENFACILITY NUMBER:
092700822
ADMINISTRATOR:SOKIMI, MOTUOMANONOFACILITY TYPE:
740
ADDRESS:4210 PRODUCT DRIVETELEPHONE:
(530) 313-0364
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:46CENSUS: 32DATE:
11/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ricky Ziese-DulayTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit and to deliver a notice of immediate exclusion for an individual (S1). LPA Moleski met with resident service director Ricky Ziese-Dulay and explained the purpose of the visit.

Ziese-Dulay said S1 was present for training. Ziese-Dulay sent S1 home immediately after being told that S1 was excluded. LPA Moleski observed S1 being led out of the facility by staff. LPA Moleski provided a copy of the exclusion order for S1.

No deficiencies were cited during this visit. An exit interview was held with Ziese-Dulay. A copy of this report will be emailed to facility representatives.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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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