A Blissful Retreat

Type of visit: Required - 1 Year

On 07/26/23 at 8:45 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Licensee Sumaiya Osman and explained the purpose of the visit. LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 5/4/2023. At 10:35 am LPA reviewed 5 residents records. At 9:15 am, LPA reviewed 6 staff records and 6 of 6 were fingerprint cleared and associated to the facility. The following deficiency was observed during the visit: Some of the staff do not have form LIC 503 The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted. .the state’s words, verbatim · CDSS document, Jul 26, 2023

Allegation investigated: Facility staff do not serve nutritious meals Facility does not have adequate meal amount of food for the residents in care

On 09/29/2022 at 10:35 AM, Licensing Program Analysts (LPA), J. Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegations. LPA met with Olivia Siu, Administrator and explained the reason for the visit. During the course of investigation, based on initial visit, LPA observed sufficient amount of food for clients in care. The staff provided a grocery list and meal menu for the month. LPA observed instructions for staff regarding the refrigerator and their personal use. Based on interviews with staff stated that the facility has the care staff cooks the meals for all the residents. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 29, 2022 · control 15-AS-20220714121257

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Annual/Random

This is an amendment to original LIC 809 dated 8/18/2022. On 9/1/2022 at 9:45am LPAs C. Fowler and Paris Watson arrived unannounced to deliver this amended report. The report of 8/18/2022 was generated under this facility in error. That report was for sister facility A Blissful Retreat, LLC- Wilson a new annual was conducted for this facility on 9/1/2022. Upon entry, LPAs observed screening station that contained hand sanitizer, masks and COVID signage. LPAs toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters. During record review, LPA observed visitors log and temperature logs for residents or staff. LPA observed facility has a copy of Mitigation Plan. The following deficiencies were observed during the visit: -At 9:50 am, LPAs observed staff not fingerprint cleared and associated to the facility. -At 10:07 am, LPAs observed a locked gate on the side yard. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 1, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87412(a)(13) · Plan of correction due date: Sep 3, 2022

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: Based on record review, the licensee did not comply with the section cited above by having staff that is not finger print cleared working at the facility which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 1, 2022

Plan of correction: Administrator will obtain finger print clearance for staff and provide documentation to CCLD by POC date Civil penalty of $100 a day is being assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87202(a) · Plan of correction due date: Sep 2, 2022

(a) All facilities shall maintain a fire clearance approved by the city, ... Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance ... protection services, or the State Fire Marshal: Based on record review, the licensee did not comply with the section cited above by locking side gate which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 1, 2022

Plan of correction: Staff removed lock during inspection. Deficiency cleared. Civil penalty of $500 is being assessed.

Type of visit: Required - 1 Year

On 12/03/2021 at 2:00 pm Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Sumaiya Islam and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 3, 2021