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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601391
Report Date: 08/20/2022
Date Signed: 08/20/2022 10:59:47 AM

Document Has Been Signed on 08/20/2022 10:59 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:BLESSARY'S HOME INC.FACILITY NUMBER:
198601391
ADMINISTRATOR:BLESSARY V. LODEVICOFACILITY TYPE:
735
ADDRESS:19515 DUNBROOKE AVE.TELEPHONE:
(310) 516-8054
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 4DATE:
08/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Jaime Duran/Rizalie BondocTIME COMPLETED:
11:10 AM
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On 08/20/22, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced visit to Blessary’s Home. The purpose of today’s visit was to conduct the Required Annual inspection, with an emphasis on infection control. LPA was greeted by Rizalie Bondoc (staff) and Jaime Duran (administrator) joined us later. And the purpose of today’s visit was explained.

There are currently (4) South Central Los Angeles Regional Center (SCLARC) consumers in placement. All (4) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 3 bedrooms, 1 staff room, 2 bathrooms, living room/office, kitchen, dining room, covered patio, indoor/outdoor activity area, laundry room housed in the attached garage.

LPA and (Bondoc) toured the entire facility inside and out. Documents are posted as mandated. Bedrooms #1, #2, and #3 are occupied by clients and contain the mandated furniture. Bedroom #4 is a staff bedroom. 2 full bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors are hard-wired and carbon monoxide detectors were complying and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Client and staff records are current, ample supply of perishable and nonperishable food, hot water temperature measured at 105.1 degrees within 105-120 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, fire extinguishers are fully charged, fire drill conducted on 06/15/22. Exit, walkways/passageways, and front/back yard are free of debris and/or hazards. The facility is in good repair.

Evaluation Report continues LIC 809C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2022
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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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: BLESSARY'S HOME INC.
FACILITY NUMBER: 198601391
VISIT DATE: 08/20/2022
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During the visit, LPA observed the following to be complying: the facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD

No deficiencies cited:

An exit interview was conducted, and a copy of the report was furnished to the administrator Jaime Duran

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2022
LIC809 (FAS) - (06/04)
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