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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609832
Report Date: 04/28/2022
Date Signed: 04/28/2022 05:51:52 PM

Document Has Been Signed on 04/28/2022 05:51 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 HOMEFACILITY NUMBER:
567609832
ADMINISTRATOR:MARTINEZ, ARLENEFACILITY TYPE:
740
ADDRESS:962 GILL AVETELEPHONE:
(805) 253-0452
CITY:PORT HUENEMESTATE: CAZIP CODE:
93041
CAPACITY: 6CENSUS: 6DATE:
04/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Arlene MartinezTIME COMPLETED:
03:06 PM
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Licensing Program Analyst (LPA) conducted a Case Management - Deficiency visit to the above facility. LPA Ascencio met with Administrator Arlene Martinez at 9:15 AM.

On 4/28/2022, starting at approximately 9:35 a.m., LPA Ascencio reviewed six (6) resident files and observed that the Needs and Service Plans for Resident #1 (R1) and R2 were not updated within the last year. Later that day, at approximately 10:00 a.m., a Medication Audit was conducted. During the Medication Audit, it was revealed that R3’s Metroprolol 50mg has not been given as prescribed for the months of February, March and April 2022, Lisinopril 20mg for the month of April 2022, and Melatonin 5mg for the month of April 2022. LPA reviewed the physician’s order for R3, dated 02/27/2022, and observed that Metroprolol 50mg is to be given one (1) tab by mouth two (2) times daily, Lisinopril 20mg is to be given 1 tab by mouth 2 times daily, and Melatonin 5mg is to be given 1 tablet by mouth once daily at bedtime.

LPA reviewed the Medication Administration Record (MAR) for R3 and observed that Metroprolol 50mg was only given 1 tab daily for the months of February, March and April 2022, Lisinopril 20mg was given 1 tab daily for the month of April 2022, and Melatonin 5mg was not given at all for the month of April 2022. Admin Martinez stated for the Metroprolol and Lisinopril, the prescribing doctor verbally told Admin to stop giving the medication as prescribed and to give the Metroprolol 50 mg 1 time daily and the Lisinopril 20mg 2 times daily. LPA asked for a written prescription describing the doctor’s orders. Admin stated they do not have the order. LPA questioned the Melatonin 5mg not being administered. Admin stated R3’s family member does not want that medication to be given due to the effect it has on R3. LPA requested for the written prescription from the doctor that states the discontinuation of the Melatonin 5mg. Admin stated they do not have the order.

2 citations were issued during today’s visit. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Copy of the report and appeal rights 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
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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Document Has Been Signed on 04/28/2022 05:51 PM - It Cannot Be Edited


Created By: Angel Ascencio On 04/28/2022 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: BLISSFUL HOME
FACILITY NUMBER: 567609832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed.
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Admin stated a new and updated medication list for R3. Admin will conduct additional medication training on all staff. Admin will provide new medication list and training materials to LPA via email : angel.ascencio@dss.ca.gov.
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This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above as R3's medication was not administered as prescribed which poses an immediate health, safety and personal rights risk to resident in care.
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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:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/28/2022 05:51 PM - It Cannot Be Edited


Created By: Angel Ascencio On 04/28/2022 at 03:32 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: BLISSFUL HOME
FACILITY NUMBER: 567609832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2022
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia. (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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Admin stated they will updated the reappraisals and present to POA for signatures. Admin to submit paperwork to LPA via email: angel.ascencio@dss.ca.gov
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This requirement is not met as evidenced by:
Based on resident records review the licensee did not comply with the section cited above as R1 and R2's reappraisal were not done annually which poses a potential health, safety and personal rights risk to residents in care.
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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:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
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