<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850237
Report Date: 08/09/2023
Date Signed: 08/09/2023 01:45:09 PM


Document Has Been Signed on 08/09/2023 01:45 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:BLISSFUL GRANNIES HOMEFACILITY NUMBER:
565850237
ADMINISTRATOR:UDDEN, JOHNNAFACILITY TYPE:
740
ADDRESS:3704 MONTE CARLO DRIVETELEPHONE:
(805) 985-4538
CITY:OXNARDSTATE: CAZIP CODE:
93035
CAPACITY:6CENSUS: 4DATE:
08/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Johnna UddenTIME COMPLETED:
01:28 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) Teresa Camara conducted a case management - incident visit to the facility regarding a late death report for resident 1 (R1). LPA initially met with staff 1 (S1) and the administrator Johnna Udden arrived at the facility at 12:45 p.m.

Interviews were conducted with S1 at 12:23 p.m. and staff 2 (S2) at 12:29 p.m. LPA requested records for R1 but they are no longer at the facility. The administrator brought the records to the facility and LPA reviewed the records at 12:48 p.m.

Records show that R1 started their most recent admission to hospice on 4/6/2023. However, the administrator did not notify Community Care Licensing (CCL) of R1 starting hospice. Regulations require the licensee notify CCL within five working days of residents starting hospice or a hospice resident being admitted to the facility.

Records show that R1 passed away on 5/7/2023, however the administrator did not report R1's death to CCL until 7/26/2023. Regulations require that the death of a resident is reported to CCL within seven days of the occurrence.

Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 809-D)

Exit interview conducted, citations issued, appeal rights discussed, and a copy of this report sent via email.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
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 2


Document Has Been Signed on 08/09/2023 01:45 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: BLISSFUL GRANNIES HOME
FACILITY NUMBER: 565850237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2023
Section Cited
CCR
87211(a)(1)(A)

1
2
3
4
5
6
7
87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of
1
2
3
4
5
6
7
Administrator will review Reporting Requirements and submit a letter of understanding of these regulations to CCL on or before 8/16/23.
8
9
10
11
12
13
14
the occurrence...(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.
8
9
10
11
12
13
14
Based on interviews and record review, licensee failed to report R1's death within 7 days of the occurrence, which poses a potential health risk to resident in care.
Type B
08/16/2023
Section Cited
CCR87632(d)(2)

1
2
3
4
5
6
7
87632 Hospice Care Waiver (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following
1
2
3
4
5
6
7
Administrator will review Hospice Care Waiver requirements and submit a letter of understanding of these regulations to CCL on or before 8/16/23. Administrator will also submit any notices that have not previously been sent for current hospice residents.
8
9
10
11
12
13
14
requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services...
8
9
10
11
12
13
14
Based on interviews and record review, licensee failed to report R1 was admitted to hospice, which poses a potential health risk to resident in care.
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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2