567609832-6-18-2021-29-AS-AASO-C44ULN-20210618154100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609832
Report Date: 06/18/2021
Date Signed: 06/18/2021 03:42:20 PM

Document Has Been Signed on 06/18/2021 03:42 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:	BLISSFUL HOME		FACILITY NUMBER:	567609832
ADMINISTRATOR:	MARTINEZ, ARLENE		FACILITY TYPE:	740
ADDRESS:	962 GILL AVE		TELEPHONE:	(805) 253-0452
CITY:	PORT HUENEME	STATE: CA	ZIP CODE:	93041
CAPACITY: 6		CENSUS: 6	DATE:	06/18/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Arlene Martinez		TIME COMPLETED:	03:00 PM

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Licensing Program Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 1:33PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Arlene Martinez and discussed the reason for the visit. Entrance interview conducted.

LPA, along with Administrator Arlene, toured the physical plant areas inside and outside at 1:40PM to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.There are 4 (four) total bedrooms for resident use – 2 (two) are shared rooms and 2 (two) are private rooms.

RESTROOMS: 3 (three) Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The office space contained a locked cabinet with resident files and medication. LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year.

The backyard had no bodies of water. Laundry room contains a locked storage cabinet for laundry supplies. The garage door was observed locked and contained the emergency food supply.

Continued on LIC 809-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

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: BLISSFUL HOME	FACILITY NUMBER: 567609832
	VISIT DATE: 06/18/2021

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KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices at 2:00PM. There are 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The facility is allowing visitors, with use of both indoor and outdoor spacing. LPA observed an insufficient supply of gowns. LPA also observed adequate supply of other Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:

- Facility to obtain 30 day supply of Personal Protective Equipment (PPE); Gowns.

No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC809 (FAS) - (06/04)

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