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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850160
Report Date: 07/08/2021
Date Signed: 07/08/2021 02:08:28 PM

Document Has Been Signed on 07/08/2021 02:08 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 HOMECARE, INC.FACILITY NUMBER:
565850160
ADMINISTRATOR:MALLARE, MAREBETHFACILITY TYPE:
740
ADDRESS:1908 BURLESON AVETELEPHONE:
(805) 206-1844
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 3DATE:
07/08/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marebeth MallareTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Martha Guzman Chavez and Brian Balisi conducted an announced Pre-licensing visit to the above facility. LPAs met with Administrator Marebeth Mallare as this is a change of ownership application from Weiss RCFE-Thousand Oaks #565801320 to Blessed Homecare, Inc. #565850160. Entrance interview conducted.

Between 9:32am – 12:26pm LPAs Guzman Chavez and Balisi toured the physical plant conducted by Administrator Marebeth Mallare. LPAs inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. LPAs also reviewed resident records, staff records, medications, and medication records The following was noted:

Facility is a single-story residence and consists of a total of six (6) bedrooms and three (3) bathrooms. There are four (4) bedrooms and two (2) bathrooms designated for resident use and two (2) rooms and one (1) bathroom designated for staff use. Bedrooms #4 and Bedroom #1 are currently vacant. Fire clearance was approved on 6/15/2021 for five (5) non-ambulatory residents and one (1) bedridden. Room #1 is designated for double occupancy and remaining resident rooms are cleared for single occupancy. Facility currently has two (2) residents with dementia. Smoke detectors and Carbon Monoxide detector were tested and functioned properly during time of visit. Fire extinguishers were observed to be fully charged from 6/07/2021. During physical plant tour LPAs observed the required postings throughout the facility.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPAs observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a drawer in the kitchen to the right of the refrigerator.

Continued on LIC809c
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2021
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: BLESSED HOMECARE, INC.
FACILITY NUMBER: 565850160
VISIT DATE: 07/08/2021
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Continued from LIC 809

Bedrooms: The resident bedrooms were properly furnished with a bed, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathrooms: LPAs observed all bathrooms were clean, properly supplied and had functional fixtures. LPAs observed all bathrooms to have grab bars and non-skid mats. The hot water was measured in each bathroom during physical plant tour and was within the required range of 105-120 degrees Fahrenheit. Bathroom #1 measured at 117.9 degrees Fahrenheit and Bathroom #2 measured at 117.3 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Medication are stored in a locked cabinet in the living area. Above the medication cabinet was a First-Aid Kit that was complete.

Outdoor Area: There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. There are two (2) fence gates that self-latch with clear passageways for emergency exit use.
Comp III was completed in conjunction with the visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure. An exit interview was conducted with Administrator, and a hard copy was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
LIC809 (FAS) - (06/04)
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