<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850160
Report Date: 11/12/2021
Date Signed: 11/12/2021 03:21:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2021 and conducted by Evaluator Martha Guzman-Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20211108103722
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: 4DATE:
11/12/2021
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Marebeth MallareTIME COMPLETED:
03:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not obtain a Physician's Report prior to admission of a resident at the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced 10-day initial complaint visit to the above facility. LPA was greeted and scanned at the door by Licensee Representative Marebeth Mallare. At this time, the reason for the visit was explained. Entrance interview conducted.

It was alleged that the “facility did not obtain a Physician’s Report prior to admission of a resident at the facility”. It was reported that on 09-25-2021, Resident #1 (R1) was placed in this facility directly from Kaiser Woodland Hills and LIC 602, TB Test, and clear Covid test were emailed directly to Administrator. After 30 days, Administrator did not have a copy of R1’s Physician's Report. According to the Reporting Party (RP), Administrator was connected directly to Kaiser staff to have medical documents resent to facility. However, Administrator did not have a working email and fax machine to receive medical documents. One week later, RP checked in with facility, but they still did not have R1’s Physician's Report.

(...Continued on LIC 9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20211108103722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/12/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(...Continued from LIC 9099...)

On 11-12-2021, at 11:56 am, LPA Guzman Chavez conducted an interview with the Administrator, and conducted resident file review for four (4) residents at 12:25 pm. Resident file review revealed that R1 was admitted to the facility on 09-25-2021; however, the LIC 602 containing the TB test was missing. Interview with the Administrator revealed that, they have not been able to receive the LIC 602 from Kaiser. In addition, the facility does not currently have a working fax machine but gave Kaiser two (2) different emails to send the report to. But, the facility has yet to receive any medical documents from the hospital. Based on interviews and resident file review, the allegation that “facility did not obtain a Physician’s Report prior to admission of a resident at the facility” is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D)

Exit interview conducted, citations issued, appeal rights discussed, and a copy of this report sent via email.

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

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20211108103722
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2021
Section Cited
CCR
87458(b)(1)
1
2
3
4
5
6
7
87458(b)(1) Medical Assessment. The medical assessment shall include: A physical exam of the resident containing a primary and secondary diagnosis, if any, results of a test for tuberculosis and any medical conditions which would preclude care of the person in an RCFE.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator stated she will obtain a Medical Assessment with TB test for R1 and submit copy to the department as POC by 11/15/2021.
8
9
10
11
12
13
14
Based on record review conducted on 11/12/2021, licensee failed to obtain Medical Assessment and TB test result for R1 which poses a potential health risk to resident in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3