565850160-7-26-2023-29-AS-ECAS-CU4TRM-20230726145746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850160
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:58:40 PM

Document Has Been Signed on 07/26/2023 02:58 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 HOMECARE, INC.		FACILITY NUMBER:	565850160
ADMINISTRATOR:	MALLARE, MAREBETH		FACILITY TYPE:	740
ADDRESS:	1908 BURLESON AVE		TELEPHONE:	(805) 206-1844
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	07/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Marebeth Mallare		TIME COMPLETED:	03:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced for a required 1-year annual inspection today at 10:00 a.m. Upon arriving at the facility, the LPA was scanned and greeted at the door by Administrator Marebeth Mallare and was explained the reason for the visit. At 10:15 a.m., the LPA, along with the administrator 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: At 10:18 a.m., the LPA observed the kitchen/dining area. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:25 a.m., LPA observed perishable food items in the refrigerator to be expired such milk, yogurt, hummus, cheese, dressings, dates of expiration ranged from Dec 28, 2022, up to Jul 25, 2023. The Administrator was advised to monitor perishable items for expiration. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The facility consists of 6 (six) total bedrooms, 4 (four) are designated for resident use and 2 (two) are designated for staff use. Staff bedrooms were observed and were occupied by staff. RESTROOMS: Observed beginning at 10:38 a.m., restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 10:39 a.m. and 10:45 a.m., hot water measured at 109.9 and 119.8 degrees Fahrenheit in the resident restrooms. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished at the time of the visit. The LPA observed the fire extinguishers to be fully charged and last serviced on 1/15/2023. Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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 5

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 HOMECARE, INC.	FACILITY NUMBER: 565850160
	VISIT DATE: 07/26/2023

NARRATIVE

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At 11:33 a.m., fire alarms and carbon monoxide detectors were tested and functioned properly. The temperature was maintained at a comfortable level of 76 degrees F. Cleaning supplies and disinfectants are stored in the locked cabinet in the laundry room.

OUTDOOR SPACE: At 10:56 a.m., the LPA observed the backyard, which had a covered outdoor area for resident use. There was an additional covered outdoor area for resident use in the front porch with two shaded benches and additional shaded seating. There are no bodies of water noted. LPA observed a detached garage with miscellaneous storage and supplies. LPA observed 2 (two) gates on both sides of the facility which were self-closing and self-latching only one is used as an emergency exit as was free of obstruction.

RECORDS: Residents’ records review began at 11:45 a.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 12:25 p.m.; medications are centrally stored and locked in a cabinet in the dining room. Medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications record as multiple medications were found not to be logged in for Resident #1 (R1) and Resident #2 (R2). Administrator stated that medications are not logged in until started. LPA advised Administrator that all medications should be logged in when received.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. 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 COVID-19.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

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 HOMECARE, INC.	FACILITY NUMBER: 565850160
	VISIT DATE: 07/26/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	PAGE 3 The LPAs obtained the following documents: - LIC500 Personnel Report - LIC9020 Client Roster 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. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 07/26/2023 02:58 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLESSED HOMECARE, INC.	FACILITY NUMBER: 565850160
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 as newly recieved medications were not logged properly in the centrally stored medication log which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/27/2023
	Plan of Correction
1 2 3 4	The Administrator Agreed to the following: 1. Log all medications received by the facility into the centrally stored medication log and notify CCL no later than the end of the day 7/27/23.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 07/26/2023 02:58 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLESSED HOMECARE, INC.	FACILITY NUMBER: 565850160
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as multiple perishable food items were discovered to be expired which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	The administrator agreed to the following: 1. Dispose of all expired food items. Plan of correction met at the time of the visit. 2. Conduct an audit of all perishable and non perishable food items and notify CCL no later than 7/28/23.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5