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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801685
Report Date: 01/12/2022
Date Signed: 01/12/2022 02:35:36 PM

Document Has Been Signed on 01/12/2022 02:35 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 II, INC.FACILITY NUMBER:
565801685
ADMINISTRATOR:JENNIFER HAMILTONFACILITY TYPE:
740
ADDRESS:2867 TANISHA COURTTELEPHONE:
(805) 522-2155
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 6DATE:
01/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jennifer HamiltonTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA met with Administrator Jennifer Hamilton and explained the reason for the visit. The LPA toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives and chemicals are kept inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: Five out of six rooms are designated for resident use. Bedrooms were observed with appropriate furnishings, clean linens and sufficient lighting. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Signs that encourage good hand hygiene were observed in all restrooms. COMMON SPACES: Living room and dining room furniture were observed to be in good condition. The fireplace is covered and inaccessible. All exits have functioning auditory devices. The LPA observed the required postings on the wall in the entry area. The backyard has a covered area equipped with furniture for resident use. The side gate door is self-latching. There were no bodies of water noted.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The LPA observed hand sanitizer throughout the space for residents and staff use. This facility has documented records of staff and resident vaccinations. The LPA observed signs throughout the space that promoted good hand hygiene, signs and symptoms of COVID-19, droplet precautions, and proper mask usage. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited at this time. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2022
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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