565850237-2-24-2022-29-AS-AASO-CBXNZX-20220224095500

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850237
Report Date: 02/23/2022
Date Signed: 02/24/2022 09:57:49 AM

Document Has Been Signed on 02/24/2022 09:57 AM - 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:	BLISSFUL GRANNIES HOME		FACILITY NUMBER:	565850237
ADMINISTRATOR:	UDDEN, JOHNNA		FACILITY TYPE:	740
ADDRESS:	3704 MONTE CARLO DRIVE		TELEPHONE:	(805) 985-4538
CITY:	OXNARD	STATE: CA	ZIP CODE:	93035
CAPACITY:	6	CENSUS: 5	DATE:	02/23/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Johnna Udden		TIME COMPLETED:	04:20 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) Angel Ascencio conducted a Pre-Licensing Inspection with Applicant Representative Helen Busch and Administrator Johnna Udden. Reason for pre-licensing is Change of Operations. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 2/9/2022. A Fire Clearance was approved for a maximum capacity of six( 6) non-ambulatory and two (2) bedridden residents on 1/4/2022. The physical plant is a single story facility located in a residential neighborhood of Oxnard, CA. The current location is licensed under JN Care Home (#565801334), operated by Nelia Gascon. A tour of the physical plant was conducted for completeness and the following observed: KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient non-perishable food to accommodate a maximum capacity of 6 residents for 7 (seven) days. There was sufficient dining and cook ware to accommodate a maximum capacity of 6 residents. Cleaning supplies were stored and locked under-sink cabinet and locked closet in the garage. Knives and other sharps were stored in a locked cabinet during tour. Water temperature was measured and was within range of 105 degree F to 120 degrees F at the time of visit. There were no visible immediate hazards observed. BEDROOMS: There are four (4) bedrooms, all of which are designated for resident use. Two (2) bedrooms are furnished for double occupancy, two (2) are furnished for single use. All bedrooms were equipped and supplied with appropriate furniture, bedding and linens. There were no visible hazards or discrepancies observed. BATHROOMS: There are two (2) bathrooms for resident use. The resident bathrooms are full bathrooms with overhead shower head, non-skid tile and shower bench. All bathrooms were supplied with appropriate paper and hygiene products. COVID-19 signs are required inside all bathrooms and were observed during the visit. Water temperatures were measured in all bathrooms and measured within the required range of 105 degrees F to 120 degrees F at the time of the visit. Continued on LIC-809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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: BLISSFUL GRANNIES HOME	FACILITY NUMBER: 565850237
	VISIT DATE: 02/23/2022

NARRATIVE

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COMMON AREAS: These include the Common Area Room and Dining Room. The common areas were
furnished to accommodate a maximum capacity of six (6) residents. The Fire safety inspection
clearance was approved on 1/4/2022. Fire extinguishers and carbon monoxide detectors were observed
throughout the facility. There were no immediate hazards observed.

A COVID-19 Screening & Hand Sanitizing Station was observed at the entrance to the facility. COVID-19 signs were observed throughout the facility common areas.

GARAGE & OFFICE AREAS: There is a Garage and an office room at the premise. Medications are stored in a locked cabinet and refrigerator in the garage. The 1st Aid Kit is stored in the locked cabinet and locked storage area. The garage was observed to be locked and contained Emergency food supplies, resident supplies and Personal Protective Equipment (PPE).

LAUNDRY: Laundry room was observed to be locked and contained laundry supplies in a locked cabinet.

BACKYARD: The backyard has a patio with furniture appropriate for outdoor use and shade for the residents. There were no visible immediate hazards or deficiencies.

COMPONENT III ORIENTATION: A Component III Orientation was completed with the Licensee
and Administrator on 2/23/2022 during pre-licensing visit for Blissful Grannies Home, #565850237.

COVID-19 MITIGATION PLAN REPORT: During today’s visit, LPAs reviewed the facility’s Plan for Epidemic
Outbreak specific to COVID-19 Mitigation Plan Report.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst
when your license has been approved. You are allowed to continue operating until you have been notified
that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your
license. Pre-licensing is complete and this facilities has no deficiencies.

Exit interview conducted. A copy of the Licensing Report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC809 (FAS) - (06/04)

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