567609832-5-17-2023-29-AS-DPEA-CY3N2H-20231130090444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609832
Report Date: 05/17/2023
Date Signed: 05/17/2023 03:29:31 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
05/12/2023 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20230512160823

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:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Arlene Martinez		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff do not provide proper incontinence care to resident in care
Staff do not provide proper food service to resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit regarding the above noted allegations. LPA initially met with staff 1 (S1) and later met with the administrator Arlene Martinez at 10:35 a.m. LPA explained the reason for the visit.

LPA conducted interviews with administrator, S1, and staff 2 (S2) starting at 9:35 a.m. LPA interviewed residents starting at 11:16 a.m. LPA reviewed and obtained pertinent documents starting at 9:50 a.m.

(continued on 9099-C, page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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 3

Control Number 29-AS-20230512160823

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: 05/17/2023

NARRATIVE

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(continued from 9099, page 1)

RE: Staff do not provide proper incontinence care to resident in care
This complaint was regarding the frequency in which staff change residents' disposable underwear and/or assist residents in the bathroom. Staff stated incontinence care is provided to most of the residents on a schedule. They get changed in the morning, around lunchtime, afternoon and late evening; or as needed based on observation or if a resident requests assistance. There is one resident who likes to use the bathroom during the daytime and one resident who always uses the bathroom with assistance from staff. Other residents require full incontinence care. Residents capable of communicating with LPA stated the staff help them with their needs. If they need to be cleaned they can let staff know. Staff will assist right away unless they are busy assisting other residents, then they may need to wait a little bit. None of the residents stated that staff did not provide them with needed incontinence care. During LPA's visit staff were assisting some residents with incontinence care. Based on interviews and observations, the allegation staff do not provide proper incontinence care to resident in care is deemed UNSUBSTANTIATED at this time.

RE: Staff do not provide proper food service to resident in care
This complaint was specifically regarding in between meal snacks and beverages. Staff stated residents are offered beverages and snacks throughout the day. They showed LPA snack options such as crackers, chips, cookies, Ensure, fruit and sometimes staff make fresh baked goods. Staff stated they have some residents who like to drink tea or coffee; others prefer water. Resident 1 (R1) likes to drink coffee in the morning and at lunch. They try to avoid giving coffee at dinner or later due to the caffeine. R1 stated they like to drink coffee and staff provide coffee to them when they ask for it. All residents stated if they want a snack or beverage they just ask for it. Staff also offer snacks to residents that cannot communicate their wants or needs. Based on interviews with staff and residents, the allegation staff do not provide proper food service to resident in care is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of report provided to administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

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