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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850160
Report Date: 07/11/2022
Date Signed: 07/11/2022 02:38:07 PM

Document Has Been Signed on 07/11/2022 02:38 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: 5DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marebeth MallareTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required 1-year annual inspection today at 12:30 p.m. This will be the first annual at the facility since the change of ownership pre-licensing visit on 7/08/2021. Upon arriving at the facility, the LPA was scanned and greeted at the door by Licensee Representative, Marebeth Mallare and was explained the reason for the visit. Entrance interview conducted.

At 12:40 p.m., the LPA began the physical plant tour with the Licensee Representative of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The facility has a sufficient supply of at least seven (7) days perishable and two (2) days non-perishable food. The LPA observed all knives and sharps locked in a drawer to the right of the refrigerator.

BEDROOMS: The LPA observed the resident bedrooms to be properly furnished with clean linens, furnishings, and sufficient lighting for each resident.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels for resident use. Bathrooms were measured for hot water, the first bathroom measured at 113.0 degrees Fahrenheit at 12:43 p.m., the second bathroom measured at 114.8 degrees Fahrenheit at 12:45 p.m., and the third bathroom was measured at 113.2 degrees Fahrenheit at 12:47 p.m.

…Continued on LIC 809C…

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 07/11/2022
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…Continued from LIC 809...

LAUNDRY/OUTDOOR AREAS: The garage is attached to the house and locked at all times. There is one (1) additional freezer with perishable items in good condition. Toxins and cleaning supplies were observed locked in a cabinet in the laundry room. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Facility has an adequate amount of emergency food and emergency water. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The facility is maintained at 76 degrees Fahrenheit. Fire extinguishers were observed to be fully charged on 6//06/2022. The LPA observed two (2) residents in the living room watching television during time of visit. Medications are stored in a locked cabinet adjacent to the dining room.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19, and CDSS PINS pertaining to visitation guidelines. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA and Administrator discussed staff vaccination requirements. All staff are fully vaccinated. Staff were observed wearing face coverings during time of visit. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

Exit interview conducted. No citations issued. Today's report was reviewed and emailed to the Licensee Representative.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC809 (FAS) - (06/04)
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