565850237-1-31-2024-29-AS-KLOZ-D2TVNH-20240226153506

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850237
Report Date: 01/31/2024
Date Signed: 01/31/2024 04:52:14 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
05/31/2022 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20220531120218

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:	01/31/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Johnna Udden		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Staff hit resident

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced subsequent complaint visit for the above allegation. The LPA arrived at 11:00 a.m., met with staff and informed them for the reason of the visit. Administrators Johnna Udden and Helen Busch arrived shortly.

On 06/02/2022, between 10:26 a.m. and 10:32 a.m., LPA Peraldi along with the Administrator, conducted a physical plant tour. At 10:01 a.m., the LPA conducted an interview with the Administrator and staff. Between 11:33 a.m. and 11:40 a.m., the LPA interviewed residents. The LPA also reviewed records at 10:35 a.m. and obtained copies of pertinent documents. During today’s visit, LPA Cortez along with Care Giver Rebeche toured the facility at 11:12 a.m., interviewed staff, residents, Resident #1 (R1) family member, and hospice social director between 1:05 p.m. and 3:20 p.m., and collected pertinent documents.

Report will continue on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220531120218

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/31/2024

NARRATIVE

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It was alleged that Staff hit resident. It was further reported that staff slap Resident #1 (R1) and covered R1’s mouth. Information gathered revealed that there has not been any residents report of being hit by any staff. Staff interviews revealed that the residents have never voiced any concerns about staff hitting them, and if they did, they would report it. Staff interviews revealed there was an incident where R1 was being showered by their Home Health bath aid, and two staff (S1,S2) heard R1 screaming and went to assist. S1 started to pat R1 on their back to calm R1 down and denies slapping R1. R1 started to spit. S1 stated they placed their hands close to R1’s face to cover themselves from the spit and denied covering R1’s mouth. S2 revealed they were present during the incident and denied observing S1 slap or cover R1’s mouth. Administrator further stated they had a meeting with the hospice agency, and R1’s family members regarding the incident. Interview with Hospice Social director revealed that the incident had been discussed during a meeting, the facility denied any claims of abuse and no other issues regarding staff were on file. On 6/02/22 LPA Peraldi interviewed R1, who stated the facility was okay and that staff was okay. LPA Peraldi also interviewed a separate resident who stated staff are fine. On 1/31/24 LPA Cortez interviewed two (2) residents who denied ever observing staff hit residents and stated they have no concerns and feel safe at the facility. In addition, the Interview, LPA Cortez conducted with R1’s family revealed that they are very happy with the care the facility provided to R1. R1’s family also revealed that R1 was visited by family weekly and they did not have any concerns, and stated staff did not hit R1. Furthermore, R1’s family stated that they had a concern with R1’s bather and after they were replaced, they never had a problem. Based on information gathered during the course of the investigation, there is insufficient evidence to support the allegation, “Staff hit resident”. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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