Blissful Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:00 A.M. The LPA met with Facility Designee, Virginia Farin, and explained the reason for the visit. Administrator on file, Arlene Martinez, was contacted via telephone. Administrator was unavailable during today's visit, but authorized Facility Designee, Virginia Farin, to sign today's reports. Entrance interview conducted. Beginning at 11:15 A.M., the LPA, along with Facility Designee, 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 two-story residence, the upstairs area is inaccessible to residents in care and is used for staff only, therefore it was not observed. Fire extinguisher was fully charged with purchase date of 06/01/2026. Hardwired smoke and carbon monoxide detectors were tested at 12:15 P.M. and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional during the visit. BEDROOMS: There are four (4) total resident bedrooms in the facility; two (2) are designated as private resident rooms and 2 (two) are designated as shared rooms. All residents’ rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The bedrooms were large enough to allow for easy passage. Bedridden bedroom #1 and bedroom #4 have exits to the exterior and attached bathrooms. LPA observed that facility is retaining bedridden residents in a room which is designated as non-ambulatory. Additionally, one resident was using supplemental oxygen; however, "No Smoking – Oxygen in Use" signage was not present in areas where oxygen was in use. Technical Violation (TV) issued. Continued on LIC 809-C Continued from LIC 809 BATHROOMS: There are 3 (three) total resident bathrooms, of which two (2) are inside resident rooms. Restrooms were observed clean with slip resistant mats, and grab bars by the showers and toilets. LPA observed that toilet located in bedroom #1 was not functioning properly as it was not flushing due to a leak. Technical Violation (TV) issued. All other toilets were in working condition. The water temperature was measured in the bathroom inside room #1 and #4 and measured 121.5 and 122.0 degrees Fahrenheit. KITCHEN: LPA inspected the kitchen at 11:45 A.M. Knives are locked in a toolbox that’s kept on the kitchen counter. 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. At 12:00 P.M. the hot water temperature measured 125.6 degrees Fahrenheit. 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. LPA observed storage space closets in hallway containing clean linens for resident use. The required postings were observed throughout the common spaces. Activities were observed stored in the living room. The fireplace was adequately screened. There is a functioning telephone on the premises. 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 a shed containing yard tools and extra mobility supplies and two (2) 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. Continued on LIC 809-C Continued from LIC 809-C RECORD REVIEW: Facility records are stored in a locked cabinet in the office room. The LPA reviewed six (6) resident files and six (6) 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) Physician’s report indicates that the resident is ambulatory, however, during today’s visit, LPA observed that R1 is non-ambulatory, also they did not have a current appraisal/needs and service plan on file and they were missing their Tuberculosis (TB) test result. Residents’ 2, 3 and 4 (R2,3&4) current appraisal/needs and service appraisal did not have signatures. Furthermore, LPA observed Resident’s 4 (R4’s) bed rails that extended the entire length of the bed; however, they are not currently receiving hospice services. All staff records were in order. The LPA reviewed the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the facility’s current liability insurance, and last emergency disaster drill. Last drill was conducted on 06/08/2026. LPA observed that facility is conducting the required quarterly emergency drills; however, a review of drill records indicated that since 2019 staff have only participated in earthquake and fire drills. LPA explained that emergency preparedness training should include a variety of disaster scenarios to ensure staff and residents are prepared to respond appropriately to different types of emergencies. MEDICATION REVIEW: Medications are locked in a cabinet in the office room. 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. During review, LPA was unable to verify whether the exact medication dosage was administered as the facility did not record start dates on the Central Stored Medication Destruction Records (CSMDR). Additionally, LPA observed that medication was being pre-popped in advance of administration. During today’s visit LPA informed the licensee and designee that removing medication from their original packaging in advance of administration (pre-popping) is not permitted. Technical Violation (TV) issued. Continued on LIC 809-C Continued from LIC 809-C INFECTION CONTROL: During today’s visit, LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. INTERVIEWS: During today's visit, LPA interviewed two (2) staff and one (1) resident. Resident interviews revealed that Administrator is not present at the facility during normal working hours and it is negatively affecting the facility’s daily operations. 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. An immediate civil penalty in the amount of $500 is being assessed on today’s date sue to a fire clearance violation. Exit interview, a copy of the report and Appeal Rights was provided to the facility designee.the state’s words, verbatim · CDSS document, Jul 16, 2026

Type of visit: Required - 1 Year

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. 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. 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.the state’s words, verbatim · CDSS document, Jul 2, 2025

The state marks this report as 14 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: 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

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 (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. (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.the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 29-AS-20240110130350

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:46AM. LPA met with Caregiver Helen Locquiao and Licensee/Administrator Arlene Martinez who arrived at 09:59AM. Entrance interview conducted. Beginning at 9:50AM, the LPA, along with the Caregiver and Licensee/Administrator 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: Fire extinguisher was last purchased 05/16/2024. Hardwired smoke and carbon monoxide detectors were tested at 10:06AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were off, however, staff turned them on and were functional at the time of 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 2 (two) days perishable and 7 (seven) days non-perishable food. Food was stored at appropriate temperatures. BEDROOMS: There are 4 (four) total 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 beds are furnished with box springs, comfortable mattress and clean linens; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. 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. Report Continued on LIC 809-C BATHROOMS: There are 3 (three) total bathrooms, of which 2 (two) are attached to resident rooms. Restrooms were observed to contain nonskid mats. Grab bars by the showers and toilets were observed in the bathrooms. The water temperature was measured in all 3 (three) bathrooms and measured between 150.2, 152.1, and 155.5 degrees Fahrenheit, which is above the required range of 105 to 120 degrees F. LPA observed storage space closets in hallway containing clean linens for resident use. COMMON AREAS: This includes the living room and dining area in the kitchen. LPA observed common areas to be clean and properly furnished at the time of the visit. OUTDOOR SPACE: The backyard does not have a covered patio area and both passageways were obstructed with a trashcan and baby gate respectively. There were no bodies of water on the premises. LPA observed a locked storage shed in the backyard. LPA observed 2 (two) latched self-closing side gates, however, 1 (one) gate was not self-latching. Administrator attempted to fix the side gate and was able to make it self-close, however, it does not latch. Administrator locked the gate which is a fire clearance hazard. GARAGE: At 10:11AM, 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. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 05/15/2024. RECORD REVIEW: LPA began record review at 10:40AM. LPA reviewed 6 (six) out of 6 (six) resident files and 4 (four) 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. LPA observed 3 (three) resident files to be missing updated and current needs and service appraisal plans. Staff files were complete and had no missing documents. Report Continued on LIC 809-C MEDICATION REVIEW: Medications are locked in a cabinet in the office. Medications for 3 (three) residents were observed. 2 (two) out of 3 (three) resident medications observed were labeled, stored, and properly documented at the time of the visit. At 11:57AM, LPA observed a night-time melatonin dose for Resident #1 (R1) was already administered today, which is not in accordance to the dosage instructions on the medication label, indicating it as a bedtime medication. INTERVIEWS: During today's visit, LPAs interviewed 2 (two) staff and 2 (two) residents. During today's visit, LPA obtained a copy of the facility's liability insurance. 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.the state’s words, verbatim · CDSS document, Jul 25, 2024

The state marks this report as 10 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.