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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609832
Report Date: 06/20/2023
Date Signed: 06/20/2023 11:30:48 AM

Substantiated


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 HOMEFACILITY NUMBER:
567609832
ADMINISTRATOR:MARTINEZ, ARLENEFACILITY TYPE:
740
ADDRESS:962 GILL AVETELEPHONE:
(805) 253-0452
CITY:PORT HUENEMESTATE: CAZIP CODE:
93041
CAPACITY:6CENSUS: 6DATE:
06/20/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Arlene MartinezTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility is operating outside license terms and conditions
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegation. LPA met with administrator Arlene Martinez and explained the reason for the visit.

On 5/17/2023, 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. LPA required further clarification regarding the ambulatory status of resident 6 (R6) as staff indicated they needed to reposition R6 and assist R6 with all activities of daily living.


(continued from 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
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: 06/20/2023
NARRATIVE
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(continued from 9099)

The administrator contacted the hospice agency for R6 and found R6 was now considered bedridden. The facility has fire clearance for one bedridden resident. Resident 5 (R5) is bedridden and occupies the one bedridden bed in the facility.

The administrator attempted to obtain additional bedridden clearance from the Ventura County Fire Department (VCFD). The VCFD inspected the facility on 6/16/2023 and informed the administrator they must have a fire sprinkler system in order to obtain clearance for more bedridden residents.

VCFD suggested to the administrator they try to obtain an exception for R6. The administrator was informed today, 6/20/2023, that CCL cannot approve an exception request for fire clearance as that is not within CCL's jurisdiction.

The allegation "Facility is operating outside license terms and conditions" is deemed Substantiated at this time as R6 is a bedridden resident in a room not fire cleared for bedridden residents.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 9099-D). Exit Interview Conducted. Failure to correct the deficiencies may result in civil penalties. A Civil Penalty in the amount of $500 was assessed during today's visit. Appeal Rights Discussed. A Copy of Report Issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2023
Section Cited
CCR
87202(a)(2)
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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the
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The administrator will issue a 30 day notice to R6 and R6's Public Guardian by 6/21/2023. The administrator will also ensure that in the meantime while R6 is still at the facility there is 24/7 awake staff to ensure the safety of all residents.
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applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.(2)Bedridden persons.
This requirement is not met as evidenced by:
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Based on observation and interviews, the licensee did not comply with the section cited above as R6 is bedridden in a room without fire clearance for a bedridden resident, which poses an immediate health, and safety risk to persons 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3