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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850160
Report Date: 05/15/2024
Date Signed: 05/24/2024 01:27:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2024 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20240430160600
FACILITY NAME:BLESSED HOMECARE, INC.FACILITY NUMBER:
565850160
ADMINISTRATOR:MALLARE, MAREBETHFACILITY TYPE:
740
ADDRESS:1908 BURLESON AVETELEPHONE:
(805) 206-1844
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 4DATE:
05/15/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Marebeth MallareTIME COMPLETED:
09:46 PM
ALLEGATION(S):
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Staff is unable to communicate effectively
Staff is not providing adequate care and supervision
Staff did not afford a resident privacy
Staff are not properly trained
Staff do not properly maintain a resident's room
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver investigation finding. Upon arrival LPA met with staff. Administrator was contacted. LPA met with Administrator and explained the reason for the visit. Entrance interview conducted.

On 04/30/2024, Community Care Licensing Division received the above complaint allegations. Investigation into the allegations consist of physical plant tour, interview with staff, and residents on 4/30/2024. In addition staff were interviewed and staff training records were reviewed on 04/30/2024 and 05/15/2024.

Following is a summary of the allegations and investigation finding:

Allegation) Staff is unable to communicate effectively – It was reported that staff #1 who lives and works at the facility is unable to communicate effectively with resident and in an emergency situation would not be able to effectively communicate with emergency personnel. (Continue to LIC9099c).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20240430160600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/15/2024
NARRATIVE
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On 05/01/2024, LPA interviewed four (4) residents and one (1) staff. Four out of four resident interviewed agreed that it is challenging communicating with staff #1 since he cannot hear. Administrator acknowledged understanding and reported that moving forward she will ensure that staff #1 is on duty with another staff.
Regarding allegation - Staff is not providing adequate care and supervision - It was reported that since staff #1 is unable to communicate effectively with the residents in care and the only staff on duty at the time, adequate care and supervision is not provided to the residents. Four out four residents interviewed including a credible witness revealed that when staff #1 is the only staff on duty adequate care and supervision is not afford to the residents especially in case of an emergency. Based on interviews, allegation “Staff is not providing adequate care and supervision” is deemed Substantiated at this time.
Regarding allegation - Staff did not afford a resident privacy - It was reported that staff were observed assisting resident with under garments in the room with the door open. Staff reported they usually do close the door when assisting residents with hygiene/toileting. Residents interviewed expressed that they really haven't paid attention if their room door is closed or left open when staff assist them with anything. Credible witness provided information that they witnessed staff assisting resident in the room with hygiene /toileting needs. Staff did not afford resident privacy by changing resident with the door open. Based on interviews, allegation “Staff did not afford a resident privacy” is deemed Substantiated at this time.
Regarding allegation - Staff are not properly trained - It was reported that the staff are not properly trained of residents care and personal rights. To investigate this allegation staff was interviewed and training records were reviewed on 5/15/2024. Training records for staff #1 were incomplete with missing training times (duration). Also interview conducted with staff #1 revealed that additional training is required for staff #1. Staff was unable to respond to questions asked by LPA regarding residents personal rights, and residents plan of care. Based on interviews, records review and observation, allegation “Staff are not properly trained” is deemed Substantiated at this time.
Regarding allegation - Staff do not properly maintain a resident's room - It was reported that there are two buckets in resident's room beside the bed. During the physical plant tour LPA observed these buckets in resident #1's room (with no lid) beside residents bed. Resident interviewed did provide any information. Staff were informed to remove the buckets from the residents room and provide a trash basket with a lid. Based on observation, allegation “Staff do not properly maintain a resident's room” is deemed Substantiated at this time.
Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D) Exit interview conducted, appeal rights discussed, and a copy of the report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20240430160600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
87468.1(a)3
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Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by.
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Licensee/Administrator agreed and reported that in-service training will be provided to staff on resident "Personal Rights". Submit copy of in-service training record and supporting documents.
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Based on observation and interviews, licensee/administrator did not comply with the above. Staff did not afford resident privacy during assistance with hygiene/toileting care in residents room. This poses a potential personal rights risk to residents in care.
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Type B
05/17/2024
Section Cited
CCR
87411(a)
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Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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Licensee/Administrator agreed and reported that staff #1 will not be left alone on duty moving forward. Submit copy of LIC500 showing appropriate staff coverage.
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Based on interviews, four out four resident agreed that staff #1 should not be on duty alone due to difficulty hearing and understanding residents needs daily and in emergency situation This poses a potential personal rights, health and safety risk to residents in care.
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20240430160600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
87303(f)
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(f) Solid waste shall be stored and disposed of as follows:(3)All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers....
This requirement is not met as evidence by:
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Licensee/Administrator removed the to buckets/trash bins from the room and will provide a trash can with a lid for resident #1's room.
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Based on observation and interview Licensee/administrator did not comply with this section cited. LPA observed to buckets/trash bin with no lid and a urine bottle hanging on the bed rail in resident #1's room.
This poses a potiential health risks to residents in care.
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Type B
05/17/2024
Section Cited
HSC
1569.625
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(b) (1)... receive appropriate training. This training shall consist of 40 hours of training....(2)...training requirements shall also include an additional 20 hours annually. This requirement was not met as evidenced by:
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Administrator agreed to read, review and provide training for all staff according to requirements in H&S code 1569.625, 1569.69, 1569.696, and 1569.618, Regulations 87411, 87705, 87707 and 87470. Submit training plan and schedule to CCL by 5/17/24.
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Based on record review and interviews the Licensee did not comply with the Health & Safety code above, staff did not have the initial or annual training requirements covering each required subject with date/time/hours which poses a potential health, safety and personnel rights risk to residents in care.
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Also administrator shall maintain the completed training for each staff according to regulations. Submit letter of understanding this requirement with staff training plan and schedule.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4