<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320216
Report Date: 11/10/2021
Date Signed: 11/11/2021 09:32:20 AM

Document Has Been Signed on 11/11/2021 09:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BLESSED BLISSFUL HOME CARE 2FACILITY NUMBER:
198320216
ADMINISTRATOR:SOMODIO, LAUREANA BFACILITY TYPE:
740
ADDRESS:2851 EAST 221ST STREETTELEPHONE:
(424) 731-6352
CITY:CARSONSTATE: CAZIP CODE:
90810
CAPACITY: 6CENSUS: 2DATE:
11/10/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Laureana SomodioTIME COMPLETED:
12:51 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 11/10/21 at 10:14 am, Licensing Program Analyst/ (LPA) Susan Campos, conducted a post licensing inspection visit at the Blessed Blissful Home Care 2 facility. LPA was allowed entry into the facility by Laureana Somodio, Administrator. The facility is licensed for six (6) non-ambulatory residents age 60 and over, and includes hospice waiver for 6. Currently, there are 2 residents, one ambulatory and one non-ambulatory, residing in the facility. LPA explained to Ms. Somodio the purpose of the visit, and escorted LPA on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Campos reviewed: (2) resident service records, (2) resident medication records, and (2) staff member record, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 11/2/21. The one story house located in a residential neighborhood consists of (4) resident bedrooms, (1) office, (2) resident bathrooms, living room, dining room, kitchen, attached garage/ storage/ laundry area, covered front porch area with seating for (2) people, and table with four chairs, and a back yard patio cover with two seat chairs and a table, and also an umbrella, table and six chairs.

No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A 2- day supply perishable and 7-day supply of non-perishable foods are present in the facility. Emergency Water/ food Storage is located in the garage. Staff are following modified diets as prescribed by doctors orders per menu posted in the facility.

LPA observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA observed the following during inspection of residents rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA observed fully stocked closet with

Continued on LIC 809C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BLESSED BLISSFUL HOME CARE 2
FACILITY NUMBER: 198320216
VISIT DATE: 11/10/2021
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
26
27
28
29
30
31
32
bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured by LPA at 11:45 am to be 107.1 degrees Fahrenheit. Facility (5) Carbon Monoxide/ Smoke Detectors hardwired and connected were tested and working properly. The facility (2) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and is in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Two (2) resident files were reviewed and found to be complete. LPA reviewed (2) resident medications and they were all found to be administered according to doctor's orders. Two (2) staff files were checked and have the required documents. The facility does not handle resident's money/cash resources. All the required documents are posted in the facility in a clearly visible area. The facility has an Administrator with valid Certificate #6032285740, Expiration Date: 10/30/22.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted and a copy of the Facility Evaluation Report was provided to Laureana Somodio.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2