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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610346
Report Date: 05/24/2024
Date Signed: 05/24/2024 05:31:26 PM


Document Has Been Signed on 05/24/2024 05:31 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:
05/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jennifer Valdes (Administrator)TIME COMPLETED:
05:30 PM
NARRATIVE
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On 05/24/2024 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management - Deficiencies visit to discuss an 3 day eviction notice given to the facility. On 05/20/2024 LPA Rios received a call from administrator Jennifer Valdes about the possibility of moving due to the increase in rent. Jennifer also stated, the facility had been unable to pay the rent for the month of May and the landlord threatened to shut off the utilities if payment was not received. On that call LPA informed Jennifer if she found another property that a new application would be needed to apply for a new license, and if she moved residents to a new location without a license it would be considered unlicensed. LPA discussed with Jennifer the importance of communicating with the Landlord and to contact the Lancaster Housing Authority. LPA also informed Jennifer if she intended to close the facility Community Care Licensing would need to receive a closure plan and residents and their responsible person(s) would need to receive a written 60 days notice before the intended eviction. LPA and Jennifer discussed in case of an emergency the facility would follow their Emergency Disaster Plan.

On todays visit LPA arrived and staff #1(S1) answered the door. At approximately 12:55 p.m. S1 contacted the administrator Jennifer Valdes and informed her LPA was at the facility. Jennifer informed LPA she was in another city and would be arriving to meet LPA later. LPA informed Jennifer the reason for the visit. According to administrator, S1 would be able to provide information and records while administrator arrived.

At approximately 1:05 p.m. LPA conducted a physical plant tour of the facility. LPA observed boxes on the kitchen counter with kitchen ware packed. LPA observed the water and power of the facility to be operable.

(Continue to LIC809-C)
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
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


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: 05/24/2024
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At approximately 1:10 p.m. S1 contacted administrator and the following information was provided to LPA. Licensee does intend to close the facility. According to Jennifer, tomorrow, 05/25/2024 residents would be moving out. Resident #1(R1) would be transferring to another licensed assisted living facility, resident #2(R2) and resident #3(R3) would be moving out to live with family. On Sunday, 05/26/2024 a moving company would be by to collect the furniture. Administrator revealed they did not provide a written 60 day notice to residents or their responsible person(s). According to the administrator she told them verbally they had an option to stay for up to 90 days but the residents' families voluntarily decided to move out and agreed to do so tomorrow.

At approximately 1:22 p.m. LPA interviewed R1, who reveled they had heard the facility was closing and they would be moving but where not sure where to. R1 also revealed they were not given a 60 day written notice. R2 was sleeping and R3 did not respond to LPAs questioning. From 1:45 p.m. to 2:30 p.m. LPA spoke to residents' Responsible Person(s) (RPs). One (1) out of the three (3) RPs reveled they were not told about a 60 days notification and three (3) of three (3) RPs had not received a 60 day written notice.

At 3:41 p.m. the Licensee Yanira Valle contacted LPA and informed LPA that they felt it would be best to close the facility and relocate the residents. Yanira confirmed the facility was late on making rent payment this month for the very first time since they started leasing the facility. Yanira went on to say they were being threaten by the landlord with shutting off the facility's utilities and were being harassed by the landlord to vacate or sale the business to him.

At 4:39 p.m. the administrator arrived and LPA reminded her to submit incident reports for each resident about the closure and forfeiture of license. Administrator informed LPA they would be sending screen shots and an eviction letter given to them by the landlord. LPA reminded Jennifer to send copies of the rent payments made for the last six months. Jennifer informed LPA they contacted the various utilities companies and they informed her because the landlords name was on the bill the landlord controlled the utilities and could shut them off. Furthermore Jennifer stated she contacted Lancaster Housing Authority and they told her the same information. The Administrator provided LPA with facility license.

Deficiency issued (refer to LIC809D). 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: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/24/2024 05:31 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: 05/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2024
Section Cited
CCR
87224(a)(5)(A)(1)

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(a) The licensee may evict a resident for one or more of the reasons...(5)Change of use of the facility. (A)The licensee may, upon no less than sixty (60) days written notice, evict a resident...1.In addition to written notice to quit requirements specified in Section 87224(d), written notice to evict due to change of use of the facility shall be made to the resident or the resident’s responsible person and shall include all requirements specified in Section 1569.682(a)(2)(A) through (F) of the Health and Safety Code.
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Administrator will provide residents and their responsible person(s) a 60 day notification and provid a copy to LPA by POC due date May 29, 2024.
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This requirement was not met as evidenced by: Based on interview and review of records the facility did not provided written 60 day notices to 3 out of 3 resdients and their resposible person(s) which poses a potential health, safety and 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: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3