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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609832
Report Date: 04/28/2022
Date Signed: 04/28/2022 05:54:33 PM

Unsubstantiated


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
04/08/2020 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 31-AS-20200408094252
FACILITY NAME:BLISSFUL HOMEFACILITY NUMBER:
567609832
ADMINISTRATOR:MARTINEZ, ARLENEFACILITY TYPE:
740
ADDRESS:962 GILL AVETELEPHONE:
(805) 827-3651
CITY:PORT HUENEMESTATE: CAZIP CODE:
93041
CAPACITY:6CENSUS: 6DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Arlene MartinezTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility staff chemically restrained residents
Facility staff administered medications without a prescription
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to close out the allegations at the above facility. LPA Ascencio met with Administrator Arlene Martinez at 9:15 AM. Entrance interview conducted.

The Woodland Hills North Regional Office (RO) received a complaint on 04/08/2020, alleging that facility staff chemically restrained residents and facility staff administered medication without a prescription. On 04/17/2020, LPA Kelly Dulek conducted the initial complaint investigation telephonically with Admin Martinez due to the situation surrounding the Coronavirus Disease 2019 (COVID-19). LPA Dulek conducted interviews with Admin Martinez and staff members, requested and obtained pertinent documents.
During today’s visit, on 04/28/2022, starting at approximately 9:35 a.m., LPA Ascencio conducted a medication audit on six (6) out of 6 residents.

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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 2
Control Number 31-AS-20200408094252
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: BLISSFUL HOME
FACILITY NUMBER: 567609832
VISIT DATE: 04/28/2022
NARRATIVE
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The medication audit revealed that all 6 residents have a current medication list signed and dated by their personal primary physicians. All prescribed orders were observed to have a matching medication. LPA observed a “staff only” medication box. Admin Martinez stated that medication is for staff usage only. Starting at 2:17 p.m., LPA Ascencio conducted staff interviews and resident interviews. Interviews with staff and residents revealed that they have not seen or heard of any resident being given different medication other than what is prescribed. Further staff interviews revealed that staff are trained in medication management yearly. Based on evidence gathered during the course of the investigation, the allegations: facility staff chemically restrained residents and facility staff administered medication without a prescription is deemed unsubstantiated at this time.

Exit interview conducted and a copy of the report provided to admin via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2