Blissful Jackson Facility

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 8:35 AM, LPA met with Licensee/Administrator Ken M Clavio. An initial application for Change of Ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 11/05/2024 for a total capacity of six (6), five (5) non-ambulatory and one(1)) bedridden residents. Fire clearance was granted on 03/14/2025. LPA Delgado observed the following: Structure: Facility was a one-story house with four (4) resident bedrooms, two (2) resident bathrooms, living room, dining area and kitchen. There was an attached one car garage in the front of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Licensee decided to make changes to the floor plan and will submit a new floor sketch with LIC200. LPA observed resident bedroom #1-shared, #3-Private and #4-Private will accommodate any non-ambulatory resident, bedroom #2-shared will accommodate (1) bedridden residents and (1) non-ambulatory. Four (4) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: The two (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 09:30 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 121 degrees Fahrenheit. (CONTINUED ON LIC 809C) (CONTINUED FROM LIC 809) Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the garage. Laundry detergents and cleaning supplies were observed in garage away from residents. Living/Family room: There was a living room with seating for all clients and TV. Linens and Hygiene Supplies: An adequate supply of linens was stored in a cabinet in the main hallway of the residence and hygiene supplies stored in the garage. Yards/Outside: Patio table and chairs were observed in the backyard. There was a gate on the East side of the property with a latch. All outdoor pathways were free of obstructions. No bodies of water observed. A storage room was observed to have a bed with linen, pillow,sofa, personal clothing inside a closet, small desk with chair, side table with lamp, floor fan, a restroom with basin, toilet and shower, shampoo under the sink. Emergency Phone Numbers, and Exit Plan: Facility sketch were observed posted in the main hallway. Obudsman poster and Let-Us-No poster observed. General items: One (1) fire extinguisher were charged and located in the kitchen. Seven (7) smoke alarms and three (3) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the Living room. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water and Food supply was observed, Component III was completed on September 9. 2025 at Riverside RO. (Continued on Page 3) (Continued from Page 2) Pre-Licensing is incomplete and the following corrections to be resolved by 10/03/2025: Obtain paper towel stand Obtain trash cans with lids for restrooms Obtain additional emergency lightning Obtain latest edition First Aid Manual Post Caution Warning labels for Hot Water Repair outdoor step Re-submit LIC200 with floor plan to CAB for changes made by the Licensee in order for Inspection by Fire Department to address Storage room An exit interview was conducted with Ken Clavio and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 22, 2025

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 4 Interview Method: Telephone interview On 8/20/2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 20, 2025