565801488-7-12-2023-29-AS-MARO-CTNTG6-20230712144236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801488
Report Date: 07/12/2023
Date Signed: 07/12/2023 02:43:00 PM

Document Has Been Signed on 07/12/2023 02:43 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BLESSED FAMILY LIVING		FACILITY NUMBER:	565801488
ADMINISTRATOR:	JENNIFER HAMILTON		FACILITY TYPE:	740
ADDRESS:	3125 LORI CIRCLE		TELEPHONE:	(805) 581-5128
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 4	DATE:	07/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jennifer Hamilton		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. The last annual conducted at this facility was on 07/20/2022. Upon arrival, the LPA was greeted by staff. The Administrator, Jennifer Hamilton arrived shortly after and the reason for the visit was explained. Entrance interview conducted.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA toured the kitchen/food service area at 10:13 a.m. Knives are stored in a locked drawer inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:15 a.m., the hot water temperature was measured in the kitchen at 118.4 degrees Fahrenheit. Cleaning supplies were observed to be locked and inaccessible at the time of the visit.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 78 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space. The fireplace was observed with a cover and inaccessible to residents in care.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLESSED FAMILY LIVING	FACILITY NUMBER: 565801488
	VISIT DATE: 07/12/2023

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Report Continued from LIC C809...

The backyard has a covered outdoor area equipped with furniture including table and chairs for resident use. The LPA observed one (1) self-latching gate with clear passageways in case of an emergency. There were no bodies of water noted at the time of visit. There is a separate laundry room, which is kept locked at all times. Cleaning supplies and disinfectants are kept locked inside the laundry room. The LPA observed a sufficient supply of emergency food and water at the time of visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six (6) designated private resident rooms. The facility has one (1) designated staff bedroom that is maintained locked at all times.

RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first bathroom measured at 109.2 degrees Fahrenheit at 10:02 a.m.; and the second bathroom measured at 105.1 degrees Fahrenheit at 10:05 a.m.

RECORDS: Records review began at 10:48 a.m.; four (4) resident records were reviewed for the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, appraisals, and current needs and services plan. All records were in order.

The LPA reviewed two (2) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All records were in order.

The LPA also audited the Administrator’s file, and it was in order.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLESSED FAMILY LIVING	FACILITY NUMBER: 565801488
	VISIT DATE: 07/12/2023

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Report Continued from LIC 809C...

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance. The last fire drill was conducted on 06/05/2023.

MEDICATIONS: Medications review began at 1:40 p.m. The medications are centrally stored and locked in a cabinet by the kitchen. Medications are labeled and checked for expiration dates. No errors found during the medication audit.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

Exit interview conducted. No citations issued. A copy of the report was provided to the Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

LIC809 (FAS) - (06/04)

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