565850237-3-8-2024-29-AS-TCAA-D36UYJ-20240308150000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850237
Report Date: 03/08/2024
Date Signed: 03/08/2024 03:00:46 PM

Document Has Been Signed on 03/08/2024 03:00 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 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: 6	DATE:	03/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Johnna Udden		TIME COMPLETED:	01:15 PM

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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual inspection. LPA met with administrator Johnna Udden and explained the reason for the visit.

LPA conducted a physical plant tour inside and outside to ensure there were not health and safety hazards and the facility is in compliance with Title 22 Regulations.

The carbon monoxide and smoke detectors were tested and functioned properly. The fire extinguisher appeared fully charged and was recently purchased in March 2024. The hot water temperature was tested in the bathrooms and ranged between 108.5*F - 111.9*F.

Infection Control: Upon entry, the facility has a sign in book and sanitizing gel. Infection Control signage was observed. The facility has a sufficient supply of Personal Protective Equipment (PPE) and can obtain more if needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.

Common Areas: Common seating area and dining room furniture were observed to be in good condition.

Kitchen: Knives are stored in a locked cabinet drawer. Cleaning supplies were stored in a locked cabinet under the sink. Appliances were in operable condition. The facility has enough supply of perishable and non-perishable food.

Bedrooms: There are four bedrooms for residents. Two are shared rooms and two are private. All bedrooms were appropriately furnished, had sufficient lighting and clean linens.

(continued on LIC809C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLISSFUL GRANNIES HOME	FACILITY NUMBER: 565850237
	VISIT DATE: 03/08/2024

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(continued from 809)

Bathrooms: There is one bathroom in the hallway and one bathroom for private use in the shared main bedroom. Bathrooms were clean, shower area was in clean condition with grab bars and a non-skid mat available. Paper towels and soap were available for hand washing.

Outdoor Space: Backyard has a covered outdoor area equipped with furniture in good repair for residents’ use. There were no bodies of water noted. Side gate is unlocked and self-latching.

Medication: LPA reviewed medications, including PRN medications, which appeared to be given as prescribed.

Interviews: LPA conducted interviews with two staff; no concerns noted. LPA was unable to interview residents due to their medical conditions.

Records: LPA reviewed records for five residents, three staff and two administrators. All documents reviewed were complete.

No citations were issued. Exit interview was conducted and report was issued to the administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

LIC809 (FAS) - (06/04)

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