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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320216
Report Date: 12/06/2022
Date Signed: 12/07/2022 08:24:06 AM

Document Has Been Signed on 12/07/2022 08:24 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
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:
12/06/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Loureana SomodioTIME COMPLETED:
01:00 PM
NARRATIVE
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On 12/06/22 at 11:00 am a non-compliance conference meeting was held for this facility. Licensee Loureana Somodio and Elaine Somodio of Blessed Blissful Home 2, Regional Manager (RM) Benita Yates, Licensing Program Managers (LPMs) Janae Hammond, and Eva Alvarez, and Licensing Program Analysts (LPAs) Ernand Dabuet and Jose Calderon were all present at this meeting. LPA Dabuet explained additional deficiencies associated with the annual required inspection on 11/27/22 will be cited.

LPA Dabuet reviewed personnel records on 11/27/22 and found files to be incomplete:
  • Lorie Somodio - Administrator (Employee Rights LIC 9052)
  • Eman Somodio - Caregiver (Incomplete file)
  • Charmaine Alcantara - Assistant Administrator (incomplete file)
  • Juliana Vasquez - Caregiver (SOC 341 & Employee Right LIC 9052)
  • Flordeliza Robles - Caregiver (Incomplete file)


The licensee and administrator failed to submit a death report LIC 624A to Community Care Licensing (CCL) for a resident who passed away at the facility in April 2022. The administrator is being cited according to Administrator's Qualifications Regulations 87405 resulting in multiple deficiencies cited.

Based on interviews and 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 Lorie Somodio A copy of this report is provided along with the appeal rights.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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 12/07/2022 08:24 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 12/06/2022 at 10:36 AM
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
, 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: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2022
Section Cited
CCR
87405(b)(2)

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87405(b)(2) Administrator-Qualificaitons and Duties. (b) The administrator of a facility or facilities shall have the responsiblity and authority to carry out the policies of the licensee. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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The licensee will create a plan to ensure that the administrator performs knowledge of and donforms to applicable laws, rules and regualitons. A written statement from licensee that reviewed 87405 proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 12/2022.
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This requirement was not met as evidence by: Based on interview and record reviews the administrator failed to adhere to Title 22 regulations, resulting to multiple citations, This violation poses a potential health and safety to residents in care.
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Type B
12/20/2022
Section Cited
CCR87211(a)(1)(A)

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87211(a)(1)(A) Reporting Requirements licensee shall furnish to the licensing agency such reports as the Department... (1) A written report shall be submitted to the licensing agency... within seven days..(A) Death of any resident from any cause regardless of where the death occurred...
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Licensee will adhere to the regulations and will ensure any changes in resident's health condition or death will be reported to CCLD. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 12/2022.
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This requirement was not met as evidence by: Based on interview and record review, administrator failed to submit a death report was not sent to CCLD for resident who passed in April 2022. This violation poses a potential health and safety to residents 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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/07/2022 08:24 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 12/06/2022 at 10:56 AM
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
, 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: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2022
Section Cited
CCR
87412(a)(1-13)

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87412 Personnel Records
a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:....

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Liensee will review 87412 Personnel Record and send complete file for each employee.
Proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 12/27/22.
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This requirement was not met as evidence by: Based on record review, all staff had incomplete records and missing required forms. This violation poses a potential health and safety to residents 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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
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