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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005637
Report Date: 10/10/2024
Date Signed: 10/10/2024 11:27:22 AM


Document Has Been Signed on 10/10/2024 11:27 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:BLESSINGS SENIOR CAREFACILITY NUMBER:
306005637
ADMINISTRATOR:BROWER-GHAHYASI, JENNIFERFACILITY TYPE:
740
ADDRESS:724 S. BIRCHLEAF DRIVETELEPHONE:
(714) 396-4321
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 5DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennifer Ghahyasi - Licensee/AdministratorTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by Fia Fernandez, Caregiver. Jennifer Ghahyasi, Licensee/Administrator joined the inspection as well. LPA explained the purpose of the inspection.

The facility is one-story home with six resident bedrooms, four resident bathrooms, kitchen, dining room, living room, staff room, attached 2-car garage and backyard with pool. Pool is enclosed on all four sides. Two sides are enclosed by a brick wall separating the yard from neighboring yards. The other two sides are enclosed by the facility. One resident bedroom has patio that leads to the pool area, however the gate leading from the patio to the pool area is permanently locked. Facility appears clean, safe and sanitary. LPA observed the facility has the necessary postings posted on the walls. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in hallway cabinets. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was serviced on 7/26/2024 according to the attached service tag. Smoke/Carbon Monoxide detector were tested and noted as operational. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen and garage. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a cabinet in the dining area. Based on medication review, LPA determined facility transferred medication between containers. A citation is being issued. Exit gate is unlocked and self-latching. LPA observed exit gate to be unobstructed. LPA reviewed three resident files and three staff files. LPAs also reviewed medication for three residents. LPA interviewed one staff and one resident.



Based on today's inspection, one citation and one technical violation are being issued. An exit interview was conducted and a copy of this report, deficiency page sand appeal rights were provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
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 3


Document Has Been Signed on 10/10/2024 11:27 AM - 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: BLESSINGS SENIOR CARE

FACILITY NUMBER: 306005637

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above in 1 out of 5 resident medications which poses a potential health risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Licensee stated that the facility will conduct a medication training. Licensee stated they will document the information covered, the staff in attendance and the date/time of the training. Licensee stated they will email LPA all documentation regarding the training by the assigned POC.
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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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