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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850440
Report Date: 07/31/2025
Date Signed: 07/31/2025 11:43:53 AM

Document Has Been Signed on 07/31/2025 11:43 AM - 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:BLISSFUL HOME OXNARD LLCFACILITY NUMBER:
565850440
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, ARLENEFACILITY TYPE:
740
ADDRESS:1920 SANFORD STTELEPHONE:
(805) 246-5096
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 0DATE:
07/31/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Arlene Martinez TIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Emily Peraldi conducted a pre-licensing visit to the above noted facility. At 10:00 a.m., the LPA met with Applicant, Arlene Martinez. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been granted for six (6) residents.

At 10:08 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents and one (1) bedridden resident. The facility is one story residential home. The facility has four (4) resident bedrooms. Bedroom #4 is designated for bedridden and has a direct exit to the outside. All residents’ rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes pillowcases and blanket (if needed). Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are no staff rooms – ‘awake night staff only’ - is required. All rooms were free of odors. All window screens were clean and maintained in good repair.

There are two (2) bathrooms in the facility. Resident bedroom #2 has a bathroom inside. The residents’ bathrooms have a shower with non-skid materials. Each shower has grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 120*F. At 10:10 a.m., the kitchen hot water temperature measured at 108.5*F. At 10:23 a.m., the bathroom hot water temperature measured at 105.1*F.

Continued on LIC 809-C.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Emily Peraldi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: BLISSFUL HOME OXNARD LLC
FACILITY NUMBER: 565850440
VISIT DATE: 07/31/2025
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Resident and staff records will be stored in a locked hallway closet. Medications will be centrally stored in a locked hallway closet. The first aid supplies were complete, including a thermometer and a current version of a first aid manual.

Kitchen knives are stored in a locked cabinet underneath the kitchen sink. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. At 10:27 a.m., the smoke detector and carbon monoxide detectors were tested and functioned properly. The facility has a central entry point for symptom screening and temperature checks for staff and visitors. There is hand sanitizer available at the entrance of the facility.
There is a fire extinguisher near the kitchen. It was fully charged and purchased on 04/24/2025. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted at the entrance of the facility. The emergency telephone numbers are posted near the entrance of the facility. Other required postings are also posted near the entrance of the facility.

Continued on LIC 809-C.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Emily Peraldi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
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: BLISSFUL HOME OXNARD LLC
FACILITY NUMBER: 565850440
VISIT DATE: 07/31/2025
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The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house. There is one (1) gate with a self-latching mechanism at the side of the house designated for emergency exits. There are no bodies of water on the premises at the present time. The garage is attached to the house and will be inaccessible to residents. Laundry units are located inside the garage. Additional cleaning supplies and household supplies are located inside the garage.

Component III was conducted in conjunction with this pre-licensing visit.

Pre-Licensing is complete, and no corrections are needed.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect the approval of your license.

Exit interview conducted. A copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Emily Peraldi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4