567609832-7-24-2023-29-AS-TCAA-CU2RSK-20230724131652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609832
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:17:20 PM

Document Has Been Signed on 07/24/2023 01:17 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 HOME		FACILITY NUMBER:	567609832
ADMINISTRATOR:	MARTINEZ, ARLENE		FACILITY TYPE:	740
ADDRESS:	962 GILL AVE		TELEPHONE:	(805) 253-0452
CITY:	PORT HUENEME	STATE: CA	ZIP CODE:	93041
CAPACITY:	6	CENSUS: 6	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Arlene Martinez		TIME COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with Administrator Arlene Martinez and explained the reason for the inspection. When the LPA arrived there were two staff and four residents present. There is currently two residents receiving hospice care services.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: LPA inspected the kitchen at 9:25 a.m. Knives are locked in a drawer and cleaning supplies are stored inaccessible in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food and food was stored at appropriate temperatures.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested at 10:05 a.m. and operational at the time of the visit. There are two fire extinguishers fully charged and last serviced 5/26/2023. The LPA observed required postings throughout the common space. No bodies of water noted. The facility has one common restroom and two private restrooms for client use. Restrooms were observed to be clean and sanitary with hand soap and paper towels. The hot water temperature measured at 106.8 degrees F. The garage is where the washer and dryer are held, including additional non-perishable food items and perishable food items in an additional refrigerator. Infection control practices were discussed. The facility has a sufficient supply of Personal Protective Equipment (PPE).

Report continued on LIC 809-C.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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 HOME	FACILITY NUMBER: 567609832
	VISIT DATE: 07/24/2023

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continued from LIC 809

BEDROOMS: The four resident bedrooms were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. This facility has a second floor for staff room.

MEDICATIONS: Medications are locked and centrally stored in the office area. At 12:30 p.m. medications for three clients were reviewed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. The LPA inspected the first aid kit, which was complete.

RECORDS: At 11:30 a.m. record review for six clients and four staff was conducted. Resident and staff files reviewed were found to be complete. The Administrator's certificate expires in October 2024. Disaster drills are conducted quarterly, of which the last drill was conducted on May 2023. At 12:50 p.m. staff and resident interviews were conducted.

No deficiencies were observed during the inspection. A copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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