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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609832
Report Date: 07/02/2025
Date Signed: 07/02/2025 04:23:11 PM

Document Has Been Signed on 07/02/2025 04:23 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BLISSFUL HOMEFACILITY NUMBER:
567609832
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, ARLENEFACILITY TYPE:
740
ADDRESS:962 GILL AVETELEPHONE:
(805) 253-0452
CITY:PORT HUENEMESTATE: CAZIP CODE:
93041
CAPACITY: 6CENSUS: 6DATE:
07/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Arlene MartinezTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 8:45AM. The LPA met with staff and explained the reason for the visit. Administrator Arlene Martinez arrived shortly thereafter. Entrance interview conducted.

Beginning at 8:55AM, the LPA, along with Caregiver Avelina Giron toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Facility is a double-story residence, second floor is solely designated for staff. Fire extinguisher was fully charged with purchase date of 04/30/2025. Hardwired smoke and carbon monoxide detectors were tested at 09:17AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional during the visit.

KITCHEN: LPA inspected the kitchen at 9:50AM. Knives are locked in a drawer next to the sink and cleaning supplies are stored inaccessible in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: There are 4 (four) total resident bedrooms in the facility; 2 (two) are designated as private resident rooms and 2 (two) are designated as shared rooms. Bedrooms #1 and #4 have exits to the exterior and attached bathrooms. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space.. The bedrooms were large enough to allow for easy passage. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

COMMON AREAS: This includes the living room, dining area, and office room. LPA observed common areas to be clean and properly furnished at the time of the visit. Report Continued on LIC 809-C, 2nd page.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/02/2025
NARRATIVE
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BATHROOMS: There are 3 (three) total resident bathrooms, of which 2 (two) are inside resident rooms. Restrooms were observed clean with nonskid mats, and grab bars by the showers and toilets. The water temperature was measured in the communal bathroom at 135.5 degrees Fahrenheit and in the bathroom inside room #4 which measured at 130.0 Fahrenheit degrees. LPA observed storage space closets in hallway containing clean linens for resident use.

OUTDOOR SPACE/GARAGE: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. LPA observed 2 (two) latched self-closing side gates. LPA toured the garage. The garage has a washer and dryer, locked cleaning supplies, an additional refrigerator and freezer, an emergency water supply and an additional pantry for extra food.

RECORD REVIEW: A review of facility files was initiated at 9:50 a.m. Facility records are stored in a locked cabinet in the office room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 06/20/2025). The LPA obtained Resident Roster, Staff Roster and Insurance liability. The LPA reviewed 5 (five) out of 6 (six) resident files and five (five) out of nine (9) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. The LPA observed the following: Resident 1 (R1) did not have a current appraisal/ needs and service plan on file and Resident 2's (R2's) physician report (LIC602) did not have pages 3-5 filled out. Staff 1(S1) did not have a health screening and TB test results on file.

MEDICATION REVIEW: Medications are locked in a cabinet in the office. Medications for two (2) residents were observed. Medications are labeled and checked for expiration dates. Facility receives a pre-generated Centrally Stored Medications and Destruction Record (CSMR) from the pharmacy where staff only need to document the start date. The following was observed: During Resident 2's (R2's) audit, the LPA observed four medications (Docusate Sodium, Olanzapine, Mirtazapine, and Melatonin) on the CSMR with the start date of 07/1/2025, however, the facility did not have Olanzapine, Mirtazapine or Melatonin for the resident; Additionally, Docusate Sodium was still being given even though observed to be crossed out from the medication list provided by Home Health. Upon observation, the Administrator stated, that Olanzapine had not been delivered yet, Mirtazapine and Melatonin were discontinued and was not aware that Docusate Sodium was also discontinued.
Report will continue on LIC809-C, 3rd page.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/02/2025
NARRATIVE
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INTERVIEWS: During today's visit, LPA interviewed three (3) residents. Resident interviews revealed that activities are not provided. The LPA did not observe any activities being provided during the visit.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 07/02/2025 04:23 PM - It Cannot Be Edited


Created By: Esther Cortez On 07/02/2025 at 03:09 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: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two restrooms where the hot water measured abovice 125 degree F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2025
Plan of Correction
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2
3
4
Licensee agrees to adjust the water temperature by 07/03/2025 and will maintain water temperature between 105- and 120-degrees Fahrenheit and submit proof to licensing.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above as R3's medications were being given eventhough they had been discontinued; one of their medications had not been filled, and start dates for medications were documented eventhough medications were not being given, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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Licensee corrected all start dates during the visit and agrees to verify with R3's physician which medications should be taken and which medications are discontinued, will call pharmacy to follow up on medication refill, and will submit proof to licensing by 07/09/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2025 04:23 PM - It Cannot Be Edited


Created By: Esther Cortez On 07/02/2025 at 03:09 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: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and nterviews, the licensee did not comply with the section cited above as interviews revealed residents are not being provided with activities and the LPA did not observe any activities during the visit which posesa potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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The licensee will submit their plan on how they will incorporate activities residents are interested in to CCLD no later than POC due date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as Resident 1 (R1) resident did not have a current appraisal/ needs and service plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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Licensee agrees to update and reappraise R1. Administrator will submit proof of the reappraisals to CCL no later than 07/09/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2025 04:23 PM - It Cannot Be Edited


Created By: Esther Cortez On 07/02/2025 at 03:33 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: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General(f) All personnel, including the licensee and administrator, shall be in good health...Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure....

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in one employee did not have proof of a negative TB test or health screening on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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2
3
4
 Licensee agree they will submit proof of a negative TB test and health screening for the identified employee no later than POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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