565801488-7-14-2025-29-AS-MARO-DJKT58-20250714142506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801488
Report Date: 07/14/2025
Date Signed: 07/14/2025 02:25:22 PM

Document Has Been Signed on 07/14/2025 02:25 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:	BLESSED FAMILY LIVING		FACILITY NUMBER:	565801488
ADMINISTRATOR/ DIRECTOR:	JENNIFER HAMILTON		FACILITY TYPE:	740
ADDRESS:	3125 LORI CIRCLE		TELEPHONE:	(805) 581-5128
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 6		CENSUS: 6	DATE:	07/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Jennifer Hamilton		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

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Licensing Program Analysts (LPA) Martha Arroyo conducted an unannounced visit to the facility to conduct the annual inspection today. Upon arrival, there were two (2) staff and six (6) residents present. The LPA met with staff who then contacted the Administrator via telephone. The Administrator, Jennifer Hamilton arrived at the facility at approximately 10:20am. Entrance interview.

The LPA along with the Administrator 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. The following was observed:

KITCHEN: The LPA inspected the kitchen/food service area at approximately 10:22am. Knives and sharps were observed in a locked drawer at the time of the visit. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Cleaning supplies were observed locked and inaccessible under the kitchen sink.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. Fire extinguisher was observed to be new with a purchase date of 04/17/2025. The LPA observed a fireplace adequately covered at the time of the visit. Nightlights observed throughout the common areas and bathrooms. The LPA observed required postings throughout the common space. Auditory alarms observed functioning at the time of the visit. The LPA observed an adequate amount of emergency food and water. No obstructions or hazards observed inside or out.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: BLESSED FAMILY LIVING	FACILITY NUMBER: 565801488
	VISIT DATE: 07/14/2025

NARRATIVE

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Report Continued from LIC 809...

RESTROOMS: There are two (2) restrooms for resident use. Bathrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in both bathrooms starting at 10:28am and they measured between 105.8 and 110.3 degrees Fahrenheit.

BEDROOMS: There are six (6) bedrooms for resident use; all bedrooms are designated for private / single occupancy. Resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The LPA observed two (2) closets with additional clean linens and towels for resident use. Staff bedroom observed on premises which is kept locked at all times.

LAUNDRY ROOM: Washer and dryer were observed in a closet adjacent to the kitchen. Detergents and toxins were observed locked and inaccessible at the time of the visit.

BACKYARD: The backyard has a shaded patio area with adequate furniture for resident use. All passageways were observed to be clear and free of obstructions. The LPA observed three (3) sheds used for storage which were locked at the time of the visit. There is one (1) self-latching gate for emergency use. No bodies of water noted at the time of the visit.

RECORDS: The LPA reviewed resident records and staff records starting at 10:45am.

Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with negative TB results, preplacement appraisal, and appraisal / current needs and services plan. All files were complete. Three (3) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments with negative TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All records were in order. Administrator’s certificate valid until 10/17/2026.

MEDICATIONS: The LPA conducted a medications review at approximately 12:25pm. Medications are centrally stored in a locked cabinet by the kitchen. Medications are being documented properly and appear to be administered as prescribed at the time of the visit. However, medications are being dispensed into separate containers 48 hours ahead of time. Staff placed medications back in original containers at the time of the visit.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025

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: BLESSED FAMILY LIVING	FACILITY NUMBER: 565801488
	VISIT DATE: 07/14/2025

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Report Continued from LIC 809C...

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. An adequate amount of Personal Protection Equipment (PPE) was observed. The LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and reviewed/updated annually. Emergency disaster drills are conducted quarterly as per regulation; with the last drill conducted on 06/20/2025.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code.

Exit interview conducted. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/14/2025 02:25 PM - It Cannot Be Edited

Created By: Martha Arroyo On 07/14/2025 at 02:03 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLESSED FAMILY LIVING	FACILITY NUMBER: 565801488
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as residents' medications are being dispensed into separate containers 48 hours ahead, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2025
	Plan of Correction
1 2 3 4	The Administrator has agreed to have in-house staff training on medications and submit proof to CCL no later than POC due date. Medications were transferred back into original containers at the time of the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:

	Martha Arroyo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025

LIC809 (FAS) - (06/04)

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