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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610346
Report Date: 01/02/2024
Date Signed: 01/02/2024 05:46:33 PM


Document Has Been Signed on 01/02/2024 05:46 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 LLCFACILITY NUMBER:
197610346
ADMINISTRATOR:VALDES, JENNIFERFACILITY TYPE:
740
ADDRESS:3244 ASHTON PLACETELEPHONE:
(818) 813-4403
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 3DATE:
01/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jennifer ValdesTIME COMPLETED:
06:00 PM
NARRATIVE
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On 01/02/2024 at 1:58 p.m. Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced case management - deficiencies visit in conjunction to complaint control number # 31-AS-20231229085809. During complaint investigation, the following was discovered:

Two staff; Staff #1 (S1) and staff #2 (S2) have no Criminal Background Clearance and/or association to the facility. S1 stated they "help out". According to the Administrator staff were hired through an agency by the name of Heaven Sent Care to provide supplemental assistance with care of residents. According to the administrator S1 started working in the facility towards the end of November of 2023. S2 has been live-in staff for approximately 2-3 weeks. LPA Rios discussed the issue with the Administrator. LPA observed staff providing residents with assistance of activities of daily living such as preparing meals, working on activities and monitoring residents in their private rooms. LPA requested LIC 500 and staff records from Administrator. Staff files were at another location and not available on todays visit.

While conducting the physical plant tour administrator notified LPA resident #1 (R1) had passed away and that is why the room was vacant. A Death Report was not submitted to the department.

While reviewing records LPA only observed incomplete Admissions Agreements for three (3) out four (4) residents on file. According to the administrator the fourth file for resident #2 (R2) was locked in the filing cabinet and R1's extensive health file was also locked. Resident files that were reviewed and available only had the admission agreements. Administrator stated records could be completed by tomorrow.




Deficiencies issued (refer to LIC809D). Civil Penalty assessed and issued (refer to LIC 421BG). Exit interview conducted. Appeal Rights provided. A copy of report was provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
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 3


Document Has Been Signed on 01/02/2024 05:46 PM - 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
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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/03/2024
Section Cited
CCR
87355(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:(1)Obtain a California clearance or a criminal record exemption as required by the Department... This requirement was not met as evidenced by:
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Administrator will remove S1 and S2 immedatley and will not allow them to return until they obtain background clearance and assosition to the facility. Administrator will sumbit all documents to LPA when complete.
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Based on interview and review of Guardian facility Staff S1 and S2 do not have criminal background clearance and association to this facility. No documentation has been submitted to Community Care Licensing. This poses an immediate health and safety or personal rights risk to clients in care.
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Type B
01/04/2024
Section Cited
CCR87211(a)(1)(A)

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87211(a)(1)(A) Reporting Requirements. The licensee shall send a written report to the licensing agency and the person responsible for the resident when a resident dies, regardless of cause or where death occurred, within seven days of the death. This requirement was not met as evidenced by:
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Administrator will submit Death Report along with the death certificate for R1 to LPA by POC due date.
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Based on interview conducted with the adminsitrator, revealed that licensee failed to submit a death report for R1 to CCL.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/02/2024 05:46 PM - 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
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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2024
Section Cited
CCR
87506(a)

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Resident Records: (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency...
This requirement is not met as evidenced by:
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Licensee agreed to complete three (3) out of four (4) resident files and submit copies to LPA by POC due date.
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Based on record review, the licensee did not comply with the section cited above. Resident records for 4 out 4 residents were incomplete and or missing documents, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
01/12/2024
Section Cited
CCR87412(a)(1)-(13)

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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...
This requirement is not met as evidenced by:
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Licensee agreed to have individual files for each staff member along with the training certificates and copies sent to LPA by POC due date.
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Based on record review, the licensee did not comply with the section cited above. Upon LPA's request Administrator was unable to provide S1's and S2's facility records. According to the administrator S1 and S2 only had job applications on file. This 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.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3