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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609832
Report Date: 02/04/2025
Date Signed: 02/27/2025 01:54:39 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
01/10/2024 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20240110130350
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:
02/04/2025
UNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Avelina GironTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff insert suppositories to residents in care without proper authorization
Residents are not provided proper food service
Facility does not have adequate staff to meet resident needs
Staff hits residents in care
Staff gave medication to resident in care without a doctor's order
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit regarding the above noted allegations. There were two staff on duty. The administrator Arlene Martinez was at an appointment and could not meet with LPA. The administrator approved caregiver Avelina Giron to sign the report for today's visit.

On 1/18/2024, LPA conducted an initial complaint investigation visit. During that visit LPA reviewed pertinent records and conducted interviews with two staff and the administrator. During today's visit LPA conducted interviews with the same two staff at 2:08 p.m. and 2:18 p.m. LPA conducted interviews with two residents; one at 2:00 p.m. and one at 2:34 p.m. LPA reviewed medications at 3:08 p.m. for two residents.

(continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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-20240110130350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLISSFUL HOME
FACILITY NUMBER: 567609832
VISIT DATE: 02/04/2025
NARRATIVE
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(continued from LIC9099)

Allegation: Facility does not have adequate staff to meet resident needs.
LPA interviewed two staff. Both staff work from morning to evening, usually Monday through Friday. Both of these staff sleep at the facility. During the evening and night shift, the licensee's husband works at the facility. If he needs assistance he can call for staff who are upstairs. There is another staff who also works at the facility when the primary staff are off. The licensee also works at the facility as a caregiver as needed. Staff feel their schedules are sufficient to meet the needs of the residents. The residents interviewed stated the staff are helpful and they do not have to wait for care when they need assistance. The facility's personnel report reflects sufficient staffing as well. Based on the information obtained through the interviews, observation and record review, the facility has adequate staff to meet the needs of the residents in care. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation: Residents are not provided proper food service.
LPA reviewed the sample menu, interviewed staff, residents, and conducted an inspection of the food supply. There was a sufficient amount of perishable and non-perishable food for balanced meals. There are a couple residents at the facility who are sensitive to vegetables and they avoid giving these residents certain vegetables, particularly at dinner time. The residents stated the like the food and get plenty of food at meals. Snacks are also offered. Based on the information obtained through observation, and interviews, the LPA observed that residents received a variety of meals and residents are happy with the meals they receive. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation: Staff insert suppositories to residents in care without proper authorization.
LPA interviewed two staff regarding suppositories. None of the residents currently at the facility have prescriptions for suppositories. Some residents are prescribed a laxative. Both staff stated they have never inserted a suppository; that is something hospice or home health staff do for residents if necessary. Staff understand they are not allowed to insert suppositories and if residents have severe, concerning constipation they will send the resident to the hospital or they notify hospice if the resident is on hospice. LPA interviewed one resident but they do not use suppositories. Based on the information obtained through observation and interviews, staff do not insert suppositories. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240110130350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLISSFUL HOME
FACILITY NUMBER: 567609832
VISIT DATE: 02/04/2025
NARRATIVE
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(continued from LIC9099C, page 2)

Allegation: Staff hit residents in care.
LPA interviewed administrator, two staff, and two residents. Staff and administrator denied any staff ever hitting residents nor have they received any complaints regarding such abuse. Residents also denied being treated poorly or being struck by staff. Residents stated staff treat them very well and are always nice. Based on the information obtained through interviews, the residents did not have any concerns about the care being provide by staff and stated that they were not aware of any staff hitting residents in care. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation: Staff gave medication to resident in care without a doctor's order.
LPA interviewed the staff and the administrator and reviewed medications. Based on a medication review of two randomly chosen residents' medications, it appears medications are being given as prescribed and properly documented. Per the Administrator and staff interviews, when residents pass away, the hospice nurse takes possession of the medications at the facility and takes the medication away to be destroyed. Based on the information obtained through interviews and record review, the allegation is deemed Unsubstantiated at this time.


No deficiencies observed. Exit interview conducted and report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3