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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530211
Report Date: 09/17/2026
Date Signed: 09/17/2026 12:49:06 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/17/2026 12:49 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BLESSED GARDEN HOME CORP.FACILITY NUMBER:
365530211
ADMINISTRATOR/
DIRECTOR:		RAMOS, LARIZA HOLCOMBFACILITY TYPE:
740
ADDRESS:935 BROOKSIDE AVENUETELEPHONE:
(909) 328-1828
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY: 6CENSUS: 6DATE:
09/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver Rose Manlolo TIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) E. Conchas made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility caregiver Rose Manlolo aka Rosalinda and was granted entry to the facility. At the time of the visit there was two (2) staff present, and six (6) residents present. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is six (6). The facility is a four (4) bedroom, two (2) bathroom home, with a kitchen/dining area, living room and an attached garage. The LPA was accompanied by caregiver Rosalinda to conduct a general overall inspection.

The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, LTCO, infection control plan, facility sketch, administrator license and the disaster plan were posted in a common area.

LPA inspected residents’ bedrooms which are equipped with required furniture, storage space, and sufficient lighting. The bathrooms were clean, and appliances were operating appropriately. Water temperature in the restrooms was measured at 110 degrees F. LPA observed sufficient furniture and lighting throughout the facility.

LPA observed the kitchen. There was sufficient Non-perishable and perishable food supply for number of residents in care. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care.

Continue to LIC809-C

Karen Clemons
Edith Conchas
DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/17/2026 12:49 PM - It Cannot Be Edited


Created By: Edith Conchas On 09/17/2026 at 11:37 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BLESSED GARDEN HOME CORP.
FACILITY NUMBER: 365530211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2026
Section Cited
CCR
87411(c)(1)

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(c) All RCFE... (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
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Licensee to ensure there is atleast one staff per shift with current CPR to provide care. . Provide a copy of completion to LPA by POC date
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LPA observed S3 works night shift. LPA observed no copy of current CPR on file which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/01/2026
Section Cited
CCR87465(h)(2)

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87465(h)(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
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Licensee to ensure any required refrigerated medication is locked and not accessible to persons other than employees responsible. . Provide an update upon correction to LPA by POC date
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LPA observed R1 insulin medication in the refrigerator accessible to any persons other than employees which poses a potential health, safety or personal rights 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/17/2026 12:49 PM - It Cannot Be Edited


Created By: Edith Conchas On 09/17/2026 at 11:58 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BLESSED GARDEN HOME CORP.
FACILITY NUMBER: 365530211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2026
Section Cited
HSC
1569.695(d)

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(d) A facility shall review the plan annually and make updates as necessary,including changes in floor plan and the population served... sign and date documentation to indicate that the plan has been reviewed and updated as necessary.This requirement is not met as evidenced by:
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Licensee to review the Emergency disaster plan, update it if needed. Train staff and maintain requirments according to regulations. Provide a copy of completion to LPA by POC date.
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LPA observed emergency disaster plan has not been signed off for review since 1/19/2024 which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/01/2026
Section Cited
CCR87470(c)(1)(D)

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(D)The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. This requirement is not met as evidenced by:
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Licensee to review the Infection control plan, update it if needed. Train staff and maintain requirments according to regulations. Provide a copy of completion to LPA by POC date
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LPA observed infection control plan has not been signed off for review since 03/9/2025 which poses a potential health, safety or personal rights 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Edith Conchas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BLESSED GARDEN HOME CORP.
FACILITY NUMBER: 365530211
VISIT DATE: 09/17/2026
NARRATIVE
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There was a designated storage space for resident/staff files. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. Medications are kept inside medication closet inaccessible to residents in care. Medications were audited at random and appeared to be dispensed appropriately by staff members. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Overall, the facility is clean and in good repair.

The following was observed and citations were issued

· Staff 3 did not have copy of current CPR in file.

· Medication was observed in the refrigerator accessible to clients.

· Emergency disaster plan was not updated.

· Infection control was not updated

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and will be provided to Caregiver Rosalinda.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC809 (FAS) - (06/04)
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