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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320216
Report Date: 11/27/2022
Date Signed: 11/27/2022 06:28:23 PM


Document Has Been Signed on 11/27/2022 06:28 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
EL SEGUNDO, 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: 6DATE:
11/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Lorie SomodioTIME COMPLETED:
04:31 PM
NARRATIVE
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On 11/27/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Lorie Somodio and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly adults of which two (2) may be ambulatory and three (3) non-ambulatory. One (1) may be bedridden. The facility is approved for four (6) hospice residents. Currently, there are four (4) hospice resident in care.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (5) resident's rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside covered patio area.

LPA and licensee toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A comfortable temperature of 72 degrees was maintained in the facility.

LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has two (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide was operable. LPA reviewed Medication Administration Records (MAR). The facility conducted a Fire/Safety Drill on 10/05/22. A working landline telephone remains available.
Evaluation Report Continues on LIC 809-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2022
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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Document Has Been Signed on 11/27/2022 06:28 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: BLESSED BLISSFUL HOME CARE 2
FACILITY NUMBER: 198320216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview) (record review), the licensee did not comply with the section cited above. LPA tested hot water temperature in bathroom #1 & 2 which resulted to 98.5 F & 100.0 F. Licensee stated there has been an ongoing issue with the hot water. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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Licensee to ensure the hot water will maintain to regulate the temperature of 105.0 F and 120.0 F. A proof of correction to CCLD by POC due date 11/28/22.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above. LPA identified water hose and laundry basked obstructing the outdoor emergency passage way. This violaton poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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Licensee to ensure keep all emergency passageway area free from obstruction. Licensee will ensure the water hose is untangle and removed from obstruction. A proof of correction to CCLD by POC due date 11/28/22.

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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/27/2022 06:28 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: BLESSED BLISSFUL HOME CARE 2
FACILITY NUMBER: 198320216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview) (record review), the licensee did not comply with the section cited above. LPA identified several toxic and hazardous items under the bathroom sinks in unlocked cabinets. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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Licensee to ensure that all staff prior to working in the facility store all toxic and hazardous items in locked storaged not accessible to residents in care. Proof of correction to CCLD by POC due date 11/28/22.

This was corrected during the visit.

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/27/2022 06:28 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: BLESSED BLISSFUL HOME CARE 2
FACILITY NUMBER: 198320216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(c)(1)(c)
87355(c)(1) (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer Request, LIC 9182.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview) (record review), the licensee did not comply with the section cited above. LPA identified staff #2 #3 and #5 (S2, S3 & S5) did not have criminal record clearance or as which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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Licensee to ensure that all staff prior to working in the facility obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by POC due date. Copies received during the time of visit. ***A CIVIL PENALTY IS BEING ISSUED TODAY***
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/27/2022 06:28 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: BLESSED BLISSFUL HOME CARE 2
FACILITY NUMBER: 198320216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(2)
87465 Incidental Medical and Dental Care
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above. LPA identified a small plastic cup filled with prescribe medication left exposed/unattended on the dining room cabitnet. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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Licensee to ensure that all staff are retrained on Title 22 Regulation 87465 and have send a written statement that staff fully understand the the immediate health and safety risk to residents in care when medications are not centrally stored. A proof of correction must be sent to LPA by POC due date 11/28/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BLESSED BLISSFUL HOME CARE 2
FACILITY NUMBER: 198320216
VISIT DATE: 11/27/2022
NARRATIVE
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INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of the resident's and staff's vaccination records was conducted. The facility has a Mitigation Plan Report on file with CCLD.

DEFICIENCIES:
Based on interviews, observation, and record reviews, LPA identified staff #2, staff #3, and staff #5 with no evidence of Criminal Record Background Clearance for the staff to be associated with the facility. LPA identified cleaning materials and disinfectants that were left under bathroom sinks in unlocked cabinets. LPA observed prescription medications contained in a small plastic cup left on the dining room cabinet exposed/unattended to the resident in care. LPA observed with the licensee a water hose and laundry basket obstructing the emergency passageway. LPA tested hot water temperature at 98.5 F and 100.0 F not compliant with Title 22 regulations.

Due to time constraints, an annual continuation will be required at a later visit.

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8,

Deficiencies are issued and an exit interview is conducted with Lori Somodio. A copy of this report, appeal rights, and civil penalty were provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2022
LIC809 (FAS) - (06/04)
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