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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601391
Report Date: 01/13/2024
Date Signed: 01/13/2024 02:07:51 PM

Document Has Been Signed on 01/13/2024 02:07 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, 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:
01/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Licensee Fe T VillaflorTIME COMPLETED:
02:30 PM
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On 01/13/2024 at 8:56 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Staff #2 (S2). Licensee Fe T Villaflor joined us later. LPA explained the purpose of the visit and was accompanied by S2 inside and outside the facility during this inspection.

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.

The facility is licensed to operate for six (6) developmentally disable adults. Ambulatory only. A total of 2 staff and 4 clients were present during this inspection.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

3 out of 3 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA Cloyd tested hot water temperature and it measured at 106 degrees Fahrenheit. This facility provides clients with hygiene products such as lotions, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

LPA observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.



Continue to LIC-809C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2024
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 16
Document Has Been Signed on 01/13/2024 02:07 PM - It Cannot Be Edited


Created By: Regina Cloyd On 01/13/2024 at 01:10 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BLESSARY'S HOME INC.
FACILITY NUMBER: 198601391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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. During the facility tour, LPA observed a damaged dresser in C1 and C4's room which poses a potentialsafety or personal rights risk to persons in care. LPA took a photo and texted it to the Administrator.
POC Due Date: 01/26/2024
Plan of Correction
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The Administrator stated that he will purchase a new dresser and send a photo to regina.cloyd@dss.ca.gov by the POC due date. Administrator will train staff to report all damages in the facility.
Type B
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for one out of four persons which poses a potential safety rights risk to persons in care. During record review, LPA observed a non-ambulatory determination by Regional Center and an ambulatory determination on the medical assessment (LIC 602) for C4. During facility tour, LPA observed C4 sitting in a wheelchair. The facility is licensed for ambulatory only.
POC Due Date: 01/26/2024
Plan of Correction
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The Administrator will email proof of correction to regina.cloyd@dss.ca.gov by the POC due date. The Administrator will ensure that all clients are ambulatory or submit a request to update the facility's license.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2024


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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BLESSARY'S HOME INC.
FACILITY NUMBER: 198601391
VISIT DATE: 01/13/2024
NARRATIVE
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LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Last Disaster drill was conducted on 12/20/23. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.

Five (5) staff records were reviewed, 5 out of 5 staff records had had required criminal record clearances or criminal record exemptions. Two staff members were interviewed.

Four (4) client records were reviewed and, 4 out of 4 client records had Admission Agreements, Medical Assessments, and Needs & Services Plans/IPP. Two clients were interviewed. Two client medications were reviewed.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

During the facility tour, LPA observed a damaged dresser in C1 and C4’s bedroom. LPA informed staff, administrator, and licensee to have it repaired. Administrator said he would purchase a new one or repair it.

During record review, LPA observed a non-ambulatory determination status by Regional Center and an ambulatory determination on C4’s medical assessment (LIC 602). During the facility tour, LPA observed C4 sitting in a wheelchair. The facility is only licensed for ambulatory residents. According to the Administrator, C4 is ambulatory and is currently having some knee problems. The Administrator said he will speak with the regional center about the document.

An exit interview was conducted, plans of corrections were developed and review, and technical assistance provided. A copy of this report and appeal rights were discussed and left with the Licensee Fe T Villaflor.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024
LIC809 (FAS) - (06/04)
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