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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801488
Report Date: 07/12/2024
Date Signed: 07/12/2024 02:06:15 PM


Document Has Been Signed on 07/12/2024 02:06 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:BLESSED FAMILY LIVINGFACILITY NUMBER:
565801488
ADMINISTRATOR:JENNIFER HAMILTONFACILITY TYPE:
740
ADDRESS:3125 LORI CIRCLETELEPHONE:
(805) 581-5128
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 6DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Jennifer HamiltonTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Trevor Byrne and Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 08:55 AM. LPAs were greeted by facility staff who contacted the facility administrator via telephone. Administrator Jennifer Hamilton arrived at the facility at approximately 09:10 AM. Entrance interview conducted.

Beginning at 08:56 AM, the LPAs, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPAs observed the kitchen/dining area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. Sufficient emergency water and food is stored in the kitchen pantry. At 08:59 AM LPAs observed two (2) bags of expired lettuce dated 06/24/2024. Staff disposed of expired items immediately. The LPAs observed one (1) designated kitchen drawer where knives and sharps are stored locked and inaccessible to residents. Cleaning supplies are located in a locked cabinet under the kitchen sink. Medication is stored in a locked cabinet in the kitchen inaccessible to residents. The kitchen contains a fireplace that was adequately screened. A fire extinguisher was observed in the kitchen and was purchased 11/29/2023.

LAUNDRY: The laundry room is located adjacent to the kitchen and is inaccessible to residents. Laundry supplies and chemicals are stored in the locked room along with the washer and dryer.

Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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 07/12/2024 02:06 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BLESSED FAMILY LIVING
FACILITY NUMBER: 565801488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 as there was a saw in an unlocked shed accessible to residents which posed an immediate health and safety risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
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Administrator secured the saw and will remove the item from the facility premises. Plan of correction (POC) cleared.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/12/2024 02:06 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BLESSED FAMILY LIVING
FACILITY NUMBER: 565801488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 as there were two (2) packages of expired lettuce in the refrigerator which posed a potential health risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Staff disposed of expired items at the time of visit. Plan of correction (POC) is cleared.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLESSED FAMILY LIVING
FACILITY NUMBER: 565801488
VISIT DATE: 07/12/2024
NARRATIVE
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Continued from LIC 809
COMMON AREAS: This includes the living room, family room, and dining room areas. LPAs observed common areas to be clean and properly furnished at the time of the visit. Night lights were observed in common hallways leading to bathrooms. A fireplace was observed in the living room to be adequately screened. Common areas were observed to contain security cameras however, they do not record audio. Hardwired smoke detectors and carbon monoxide detectors were observed and were installed and tested on 07/09/2024.

BEDROOMS: There are seven (7) bedrooms in the facility; six (6) bedrooms are designated for private resident use, as well as one (1) staff room. The staff room is kept locked. All 6 (six) resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, night lights, and sufficient lighting.

BATHROOMS: There are two (2) bathrooms for resident use. Restrooms were observed to contain nonskid mats. Grab bars were observed in the shower and near the toilets in both bathrooms. The water temperature was measured in both resident bathrooms and measured between 111.6 and 113.7 degrees Fahrenheit, which is in compliance with regulation.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including tables and chairs for resident use. Facility has one (1) self-latching gate for emergency exit use, all passageways were observed to be clear. There were no bodies of water on the premises at the time of the visit. The backyard contains three (3) unlocked storage sheds which contain extra supplies. One (1) unlocked shed was observed to contain a hand saw accessible to residents. Administrator removed and secured the saw immediately.



RECORD REVIEW: Began at 09:37 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Six (6) out of six (6) resident files contained all required documents. And four (4) out of four (4) staff files contained all required documents.

Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLESSED FAMILY LIVING
FACILITY NUMBER: 565801488
VISIT DATE: 07/12/2024
NARRATIVE
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Continued from LIC 809-C

MEDICATION REVIEW: Began at 10:21 AM. Medications for three (3) of six (6) residents were reviewed. All medications observed had the start dates written on the prescription labels. All medications reviewed were properly stored and logged in the centrally stored medication and destruction record.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency drills are conducted quarterly with the last drill conducted on 06/10/2024.

INTERVIEWS: LPAs interviewed two (2) staff and one (1) resident. LPAs attempted to interview an additional resident but were unable to obtain a response.

During today’s visit LPAs obtained a copy of the facilities liability insurance.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Licensee was advised that failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
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