197610346-6-2-2023-31-AS-ERIS-CSEQXG-20230602123332

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610346
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:33:39 PM

Document Has Been Signed on 06/02/2023 12:33 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BLESSED SENIOR LIVING CARE, LLC		FACILITY NUMBER:	197610346
ADMINISTRATOR:	VALDES, JENNIFER		FACILITY TYPE:	740
ADDRESS:	3244 ASHTON PLACE		TELEPHONE:	(818) 813-4403
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 0	DATE:	06/02/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jennifer Valdes		TIME COMPLETED:	12:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/02/2023, Licensing Program Analyst (LPA) Evelin Rios conducted an announced Pre-Licensing visit to the facility mentioned above. LPA met with applicant Jennifer Valdes. The purpose of today’s visit was explained. This is an initial application for an RCFE. A fire clearance dated 12/09/2022 was received for five (5) non-ambulatory residents and one (1) bedridden resident for a total capacity of six (6) residents. At 10:00 a.m. LPA and applicant toured the physical plant inside and out. LPA observed the following: Entry: LPA observed required postings such as the emergency exit plan/sketch, emergency exiting plan with telephone numbers, facility theft and lost program, and Licensing complaint information. Living Room: The living room is furnished with comfortable seating and a television. There is a fireplace not in use with adequate screen. Office: LPA observed a medication cart with lockable drawers where the Centrally Stored Medications will be kept locked. LPA observed a first aide kit on the medication cart. Resident and staff records will be kept in a locked cabinet in the office. Kitchen: The facility has three fire extinguisher one of three is located on a wall by the kitchen that was observed fully charged with purchase date of 09/2022. There are two functioning telephones on the premises, one by the kitchen and the other in the adjacent living room. Knives will be kept locked in a kitchen cabinet. The pantry contained a seven-day supply of non-perishable foods and the refrigerator contained a 2-day supply of non-perishable foods. LPA observed the facility menu posted on a wall in the living room. LPA observed enough plates, cups and silverware for the capacity of the facility. LPA observed board games and activities for residents. Dining Area: LPA observed a dining table with chairs able to seat the capacity of the facility and a second table with chairs located by the kitchen.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLESSED SENIOR LIVING CARE, LLC	FACILITY NUMBER: 197610346
	VISIT DATE: 06/02/2023

NARRATIVE

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Hallway Closets: Hallway closets contained extra clean linens and bathroom supplies.

Bedrooms: There are five (5) resident bedrooms and one is meant to be shared by two residents. Each bedroom has required bed with linens, night stand, lamp, chair, drawer and a closet for the number of residents in the bedroom.

Bathrooms: There are three (3) bathrooms in the facility. One bathroom is located in the shared bedroom for private use of the residents. There are two (2) bathrooms located in the hallways. The bathrooms contained, hand soap, paper towels, toilet paper, and trash bins. At 10:44 a.m. LPA tested the water temperature in the resident's hallway bathroom, water temperature read between 105-120 degrees F.

Laundry/Garage: There is a laundry room leading to the garage. Laundry detergent and cleaning products are kept locked in the garage and will be inaccessible to residents. The facility has an extra refrigerator where they will be storing medication that requires refrigeration.

Door Alarms: There are auditory devices in place on all exit door or sliding glass doors of the facility. LPA observed them to be functioning properly.

Outdoor area: There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced and there are no bodies of water. Side gate was closed but not locked.

Smoke/Carbon Monoxide Detectors: Hard wired smoke and carbon monoxide detectors were observed through out the facility. At 11:17 a.m. LPA observed applicant test the carbon monoxide detector in the kitchen and it was observed to be function properly.

LPA reviewed COMP III presentation with applicant.

Pre-Licensing is complete and this facility has no deficiencies. This report will be forwarded to the Centralized Application Bureau (CAB). The Applicant will be notified by the CAB Analyst when the facility license has been approved. Exit interview was conducted and a copy of the report was signed and provided to the Applicant.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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