306006293-7-10-2024-22-AS-ARJR-D72RQ5-20240710131258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006293
Report Date: 07/10/2024
Date Signed: 07/10/2024 01:13:04 PM

Document Has Been Signed on 07/10/2024 01:13 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BLESSINGS SENIOR CARE #2		FACILITY NUMBER:	306006293
ADMINISTRATOR:	GHAHYASI-BROWER, JENNIFER		FACILITY TYPE:	740
ADDRESS:	2586 N. ORANGE HILL LANE		TELEPHONE:	(877) 612-5477
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 6	DATE:	07/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:09 AM
MET WITH:	Herminiapaz Navarro-Caregiver		TIME COMPLETED:	01:26 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Herminiapaz Navarro.

For today’s visit, LPA observed a total of six residents in care and two staff members on duty.

LPA Ramirez toured the interior and exterior portions of the facility with Navarro. The facility is a two-story structure and is licensed for six non-ambulatory residents, of which six may be on hospice and zero bedridden. There are a total of eight bedrooms of which six are for residents and two for staff. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of five restrooms of which four are for residents and one for staff. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 107.7-116.8 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. LPA observed that the fire extinguisher was charged and mounted by the resident's bedroom hallway.

During the visit LPA observed that the residents were having lasagna, fruit, juice, milk and/or water for lunch.

CONTINUED ON LIC809-C..

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

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 07/10/2024 01:13 PM - 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BLESSINGS SENIOR CARE #2	FACILITY NUMBER: 306006293
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed that the last emergency drill was conducted on 10/2023. Licensee to conduct quarterly drills taking into account different emergency scenarios.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Licensee to provide an updated documentation of the quarterly drills to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BLESSINGS SENIOR CARE #2	FACILITY NUMBER: 306006293
	VISIT DATE: 07/10/2024

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LPA Ramirez observed the emergency disaster and evacuation plan, which is located by the staff office area. Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications were locked and inaccessible to residents in care.

For the exterior portion, LPA Ramirez observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard, which both are self-closing and self-latching. No bodies of water were observed.

LPA reviewed three resident files and two staff files. LPA interviewed residents and staff present.

For today's visit one deficiency was issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with facility representative.

A copy of this report was provided at the time of exit

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

LIC809 (FAS) - (06/04)

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