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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320216
Report Date: 08/07/2024
Date Signed: 08/08/2024 03:42:13 PM

Document Has Been Signed on 08/08/2024 03:42 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:BLESSED BLISSFUL HOME CARE 2FACILITY NUMBER:
198320216
ADMINISTRATOR/
DIRECTOR:		SOMODIO, LAUREANA BFACILITY TYPE:
740
ADDRESS:2851 EAST 221ST STREETTELEPHONE:
(424) 731-6352
CITY:CARSONSTATE: CAZIP CODE:
90810
CAPACITY: 6CENSUS: 4DATE:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Laureana SolmodioTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 08/07/2024, Licensing Program Analyst (LPAs) Brown and Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with Administrator Lauerana Somodio as the purpose of today’s visit was explained. The facility is licensed to serves 2 ambulatory and 3 non-ambulatory of which one is bedridden. The facility is approved for 6 hospice resident. Currently the facility has 2 residence on hospice care.

The facility currently serves 1 ambulatory, 2 non-ambulatory and 1 bedridden for adults ages 60 and over. Current census is: 4. The facility fees is a $0 balance.

LPAs observed First Aid Kit was maintained. The facility has currently liability insurance on file effective 08/21/2023 - 08/21/2024.

The facility has a current Administrators Certification for Laureana Somodio #7009508740 expires 10/30/2024 and Elaine Somodio #7030651740 expires 07/10/2025.

The facility is a single-story structure located in a residential neighborhood and consists of the following: The home consists of 5 Bedrooms, 2 Bathrooms, a linen closet, living room, dining area, kitchen, a stocked pantry, an outdoor shaded activity area, an attached garage is used for extra storage and a washer and dryer as well as a deep freezer.

LPAs conducted a records review of 5 staff record and 3 resident records, and 4 Medication Administration Records. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire drill was conducted on 08/02/2024, 2 fire extinguishers fully charged, 6 smoke detectors combined with carbon monoxide are operational, internet and a landline was observed.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BLESSED BLISSFUL HOME CARE 2
FACILITY NUMBER: 198320216
VISIT DATE: 08/07/2024
NARRATIVE
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All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured at 109.3. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to residents, there are no firearms nor bodies of water on the premises. Exits/ walkways around the facility were free of debris and hazards. LPAs observed the facility has a supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

During the inspection, LPAs Brown and Dabuet audited staff file and identify the following
4 employees (Staff #1,#3-5) had no criminal clearance background transfer, no associate to this facility(LIC 9182)in each file. Staff #1 had a incomplete file. For resident #4 is missing annual medical assessment and need/service appraisal who is diagnosed with Dementia (last assessment was in 2022). LPAs identifies Resident #3 who is not on hospice care with full bed rails. LPAs identified both exterior gates have padlocks.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Lauerana Somodio and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
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Document Has Been Signed on 08/08/2024 03:42 PM - It Cannot Be Edited


Created By: Zina Brown On 08/07/2024 at 01:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(1)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates.

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. LPAs observed two exterior front gates had padlocks in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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Licensee will adhere to Title 22 Regulation 87705(l)(1) and remove padlocks from front gate exterior or notify licensing agency for an exemption to maintain gate locks. Proof of correction must be sent to zina.brown@dss.ca.gov within 24 hours of POC due date.
Type A
Section Cited
CCR
87355(e)(2)
(e) All individuals subject to a criminial record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunterring in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on audit review of records, the licensee did not comply with the section. LPAs identified staff #1,3-5 did not have a Criminal Clearance Background Clearance Transfer associated at this facility. This violation poses an immediate health, safety or personal rights to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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Licensee to ensure staff prior to working in the facility obtain a Criminal Background Clearance and Criminal Background Transfer Request and proof of correction to zina.brown@dss.ca.gov by POC due date.
*A CIVIL PENALTY IS BEING ISSUED TODAY*
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 Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


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Document Has Been Signed on 08/08/2024 03:42 PM - It Cannot Be Edited


Created By: Zina Brown On 08/07/2024 at 01:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on[observation and record review, the licensee did not comply with the section cited above. LPAs identify Resident #2 did not have an admission agreement on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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Licensee shall adhere to Title 22 Regulation 87507(c) and ensure all residences have a completed admissions agreement on file. Proof of correction for Resident #2 must be sent to zina.brown@dss.ca.gov by POC due date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPAs identify Resident #3 who is not on hospice had full bed rails. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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Licensee shall adhere to Title 22 Regulation 87608(a)(5)(A) and ensure the bed rails will be removed or Resident #3 will show proof of authorization from hospice. Proof of correction for Resident #3 must be sent to zina.brown@dss.ca.gov by POC due date.
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 Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


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Document Has Been Signed on 08/08/2024 03:42 PM - It Cannot Be Edited


Created By: Zina Brown On 08/07/2024 at 01:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia (c) Licensees. . . shall be responsible for ensuring the following (5) an annual medical assessment. . .a reappraisal done at least annually. . .shall include. . .resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews the licensee failed to ensure that residents who are diagnosed with dementia Resident #4 obtained an annual medical assessment and medical appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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The licensee agreed to obtain a medical assessment for Resident #4 and will create a plan to ensure that each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment.
Proof of correction will be submitted to CCL via email at Zina.Brown@dss.ca.gov
The licensee may ask for an extension if more time is needed via email.
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 Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


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Document Has Been Signed on 08/08/2024 03:42 PM - It Cannot Be Edited


Created By: Zina Brown On 08/07/2024 at 02:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(1-13)
The licensee shall ensure that personnel records are maintained on licensee, administrator and each employee. Each personnel record shall contain the following information

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Staff #1 had incomplete records and missing required forms. This violation poses a potential health and safety to residents in care.
POC Due Date: 08/28/2024
Plan of Correction
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Licensee will review 87412 Personnel Record and send complete file for Staff #1.
Proof of correction sent by email: Zina.Brown@dss.ca.gov by POC due date
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 Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


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