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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850237
Report Date: 01/31/2024
Date Signed: 01/31/2024 04:53:05 PM


Document Has Been Signed on 01/31/2024 04:53 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
WOODLAND HILLS N.ASC, 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: 5DATE:
01/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Johnna UddenTIME COMPLETED:
04:55 PM
NARRATIVE
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Analyst (LPA) Esther Cortez conducted a case management - deficiencies visit inspection due to a deficiency observed during the investigation of complaint control #29-AS-20220531120218

The LPA met with Administrator Johnna Udden and explained the reason for report.

During the complaint investigation, the following deficiencies were observed:

During today's visit, LPA observed Lysol wipes in Rm3, the kitchen counter, and in the unlocked laundry room accessible to residents in care.

At 11:18 a.m. the LPA observed an unlocked shed in the back yard with a bed, grooming/hygiene items, clothing, a purse, a box of Amoxicillin 500mg capsules, a box of AZO urinary pain relief maximum strength tablets, and small cans of paint accessible to residents in care.

At 1:36 p.m., the LPA observed, grooming/hygiene items, vapor rub, Lysol wipes, a bottle of 10% povidone-iodone solution, wound cleanser, and a tube of Phytoplex protectant Z-guard paste in room 3. Resident in room 3 cannot manage their own medication and is at risk if allowed direct access to personal grooming and hygiene items per their LIC602.

Facility serves residents with Dementia.

Citations Issued. See LIC 809-D. Appeal Rights discussed and copy of report issued.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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 01/31/2024 04:53 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BLISSFUL GRANNIES HOME
FACILITY NUMBER: 565850237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2024
Section Cited
CCR
87705(f)(2)

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87705 (f)(2) Care of Persons with Dementia. The Following shall be stored inaccessible…:over the counter medication,…toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by:
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POC has been cleared. Administrator locked the shed and removed all items from room 3 and disinfectant wipes and stored all items inacceble to residents in care during the visit..
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Based on LPA's observations, the licensee did not comply with the section cited above as over the counter medications, and toxic substances were observed at the facility accessible to residents which posed an immediate health risk to residents in care.
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Type B
02/05/2024
Section Cited
CCR87307(a)(B)

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87307(a)(B) Personal Accommodations and Services Living accommodations... shall ... provide...privacy for the residents, staff...(B) No room commonly used for other purposes shall be used as a sleeping room...This requirement is not met as evidenced by:
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The Administrator has agreed to do the following: Submit proof the shed has been cleaned out and only use for storage. Submit by 2/05/2024.
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Based on observation, the licensee failed to ensure that common areas were used appropriately, LPA observed a bed, and personal items in the she which poses a potential 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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