565801685-7-29-2024-29-AS-MARO-D7MQTC-20240729122654

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801685
Report Date: 07/29/2024
Date Signed: 07/29/2024 12:27:29 PM

Document Has Been Signed on 07/29/2024 12:27 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 II, INC.		FACILITY NUMBER:	565801685
ADMINISTRATOR:	JENNIFER HAMILTON		FACILITY TYPE:	740
ADDRESS:	2867 TANISHA COURT		TELEPHONE:	(805) 522-2155
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 4	DATE:	07/29/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Jennifer Hamilton		TIME COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced case management visit at 10:15 a.m. The purpose of this visit is to conduct an investigation regarding a self-reported incident and SOC 341 that occurred on 07/06/2024. Upon arrival, the LPA met with staff. The Administrator, Jennifer Hamilton arrived shortly after and the reason for the visit was explained. Entrance Interview.

On 07/13/2024, the Department received an incident report stating on the 07/06/2024, Resident #1 (R1) was up all night agitated and yelling for R1’s mom to call the police. R1 refused to get help and constantly got out of their room. When R1 woke up on Sunday morning, R1 had a bruise on their arm. R1 has gotten bruises easily in the past and R1’s family had also states this was a problem since R1 is taking aspirin. R1’s family brought a bruise cream for when R1 moved in. bruise was reported to R1’s family on Sunday morning. By Monday afternoon, R1’s family had picked up R1 to go shopping; however, R1’s family called the facility and said they were not bringing R1 back to the facility.

During today’s visit, LPA Arroyo conducted a plant tour at 10:33 a.m. to ensure there are no health and safety hazards, conducted interviews with the Administrator, two (2) staff members, two (2) residents, and one (1) family member between 9:40 p.m. and 11:30 a.m., conducted a file review at 10:50 a.m., and obtained copies of pertinent documents relevant to the investigation.

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: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

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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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 II, INC.	FACILITY NUMBER: 565801685
	VISIT DATE: 07/29/2024

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Report Continued from LIC 809...

Record review of R1’s physician’s report dated 05/17/2024 indicated that R1 was confused/disoriented, had sundowning behavior; however, was also able to follow instructions and able to communicate their needs. Interviews conducted with staff revealed that R1 bruised easily; therefore, R1’s family was bringing bruise cream to apply on them when they visited the facility. Progress notes for R1 revealed that at separate occasions, a bruise was observed on R1; however, the facility was keeping an open communication with R1’s family and was notating any chances to R1’s family immediately. Interviews conducted with residents revealed that the facility staff is great and attentive to all residents. Residents did not display or report any concerns with staff while living at the facility. Residents also denied staff being aggressive or physically abusive to any residents while at the facility. Furthermore, during an interview with a resident family, family member stated that facility staff communicated well at all times and added that staff cared for all residents and had no concerns with any staff working at the facility.

Based on the information obtained and reviewed, current residents and their family members have no concerns with facility staff acting inappropriately or being physically aggressive with the residents. Therefore, based on this review, no further follow up is required at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

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