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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850160
Report Date: 07/30/2024
Date Signed: 07/30/2024 04:41:30 PM

Document Has Been Signed on 07/30/2024 04:41 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BLESSED HOMECARE, INC.FACILITY NUMBER:
565850160
ADMINISTRATOR/
DIRECTOR:		MALLARE, MAREBETHFACILITY TYPE:
740
ADDRESS:1908 BURLESON AVETELEPHONE:
(805) 206-1844
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:43 AM
MET WITH:Marebeth MallareTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:43AM. LPA met with Caregiver Lourdes Claro and Licensee/Administrator Marebeth Mallare who arrived at 10:05AM. Entrance interview conducted.

Beginning at 9:44AM, the LPA, along with the Caregiver and Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers are fully charged and were last serviced 01/14/2024. Hardwired smoke and carbon monoxide detectors were tested at 11:02AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional and operating.

KITCHEN: LPA inspected the kitchen at 9:44AM. Knives and sharps are stored in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of 2 (two) days perishable and 7 (seven) days non-perishable food and an emergency water supply. Food was stored at appropriate temperatures.

BEDROOMS: The facility consists of 6 (six) total bedrooms, 4 (four) are designated for resident use and 2 (two) are designated for staff use. Staff bedrooms were observed and were occupied by staff. 2 (two) out of 4 (four) resident rooms have exits to the exterior. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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 7
Document Has Been Signed on 07/30/2024 04:41 PM - It Cannot Be Edited


Created By: Angela Barutyan On 07/30/2024 at 03:20 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 HOMECARE, INC.
FACILITY NUMBER: 565850160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 (one) out of 5 (five) staff/volunteers did not have a transfer of criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Administrator agrees to have volunteer associated by 07/31/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/30/2024 04:41 PM - It Cannot Be Edited


Created By: Angela Barutyan On 07/30/2024 at 03:20 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 HOMECARE, INC.
FACILITY NUMBER: 565850160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Administrator did not have full initial staff training as required and outlined above. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Administrator agreed to gather and review staff training completed by the staff and provide the required training records as outlined above to CCL by 08/16/2024.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/30/2024 04:41 PM - It Cannot Be Edited


Created By: Angela Barutyan On 07/30/2024 at 03:23 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 HOMECARE, INC.
FACILITY NUMBER: 565850160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)
Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee/administrator did not comply with the above. Staff did not afford resident privacy during assistance with hygiene/toileting care in residents room. This poses a potential personal rights risk to residents in care.
POC Due Date: 08/06/2024
Plan of Correction
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Licensee/Administrator agreed and reported that in-service training will be provided to staff on resident "Personal Rights". Licensee/Administrator will email a copy of in-service training record and supporting documents to CCL by 08/06/2024.
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above in that 4 (four) medications were not properly logged which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2024
Plan of Correction
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Administrator will submit a statement of understanding of the section cited above to CCL by 08/06/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 07/30/2024 04:41 PM - It Cannot Be Edited


Created By: Angela Barutyan On 07/30/2024 at 03:23 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 HOMECARE, INC.
FACILITY NUMBER: 565850160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the outside side exit doors do not self-close which poses a potential health and safety risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Administrator agrees to install a spring to the exit door for it to self-close. Administrator will email either a picture of the completed repairs or a quote for the repair/installation to CCL by 08/09/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLESSED HOMECARE, INC.
FACILITY NUMBER: 565850160
VISIT DATE: 07/30/2024
NARRATIVE
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LAUNDRY ROOM: LPA observed the locked laundry room adjacent to the kitchen. Laundry room has a washer and dryer and locked cleaning supplies. Staff rooms and staff bathroom are accessed through the laundry room.

BATHROOMS: There are 4 (four) total bathrooms, of which 1 (one) is attached to resident room and 1 (one) is for staff use. Restrooms were observed to contain nonskid mats and grab bars by the showers and toilets. Water temperatures in all 3 (three) resident bathrooms were measured between 105.7 and 116.7 degrees Fahrenheit, which is within the required range. LPA observed storage space closets in hallway containing clean linens for resident use.

COMMON AREAS: This includes the family room, TV room, and dining room. LPA observed common areas to be clean and properly furnished at the time of the visit. Facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA observed surveillance cameras in the common areas, however, they were not operating at the time of the visit.

OUTDOOR SPACE: The backyard has a covered patio area with furniture including a table and chairs. There were no bodies of water on the premises. LPA observed a locked shed containing miscellaneous supplies. At 10:25AM, LPA observed the 2 (two) side exit doors outside to self-latch but failed to self-close. Only 1 (one) pathway is used as an emergency exit which was free of obstruction.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 06/01/2024.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLESSED HOMECARE, INC.
FACILITY NUMBER: 565850160
VISIT DATE: 07/30/2024
NARRATIVE
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RECORD REVIEW: LPA began record review at 10:31AM. LPA reviewed 5 (five) out of 5 (five) resident files and 4 (four) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Resident files were complete and had no missing documents. At 10:08AM, LPA observed Staff #1 (S1) assisting Resident #1 (R1) with undergarments with the door open, failing to afford R1 privacy. LPA observed S1’s facility file to not contain trainings on residents’ rights. LPA and administrator discussed the importance of residents’ rights. At 12:10PM, LPA observed 1 (one) staff file to be missing 40 hours initial training records. LPA and administrator discussed training requirements. LPA explained how many hours per training topic is required and provided administrator with resources for initial and continuing trainings.

MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the dining room. LPA began medication review at 01:10PM and medications for 2 (two) residents were observed. 1 (one) out of 2 (two) resident medications observed were labeled and stored properly. At 1:20PM, LPA observed 4 (four) medications not logged properly on the centrally stored medication and destruction record.

INTERVIEWS: During today's visit, LPAs interviewed 1 (one) staff and 2 (two) residents.

During today's visit, LPA obtained a copy of the facility's liability insurance. The facility’s insurance expired 1 (one) day ago on 07/29, however, administrator has already submitted a renewal.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty was issued in the amount of $500. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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