Blessed Home for Seniors IV

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sommer Hayes arrived unannounced to conduct a Required - 1 Year visit on 8/15/25. LPA was met by staff member and later met with Ma Magnolia Tolon, Designated Facility Administrator arrived and stated the purpose of today’s visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents during this visit. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 117.0*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA Hayes requested the following annual documents for the facility file: LIC 500 Personnel Report, LIC 308 Designation of Responsibility, LIC 610 Emergency Disaster Plan, LIC 999 Facility Sketch, Copy of Administrator’s Certificate. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 2 staff and 2 resident files during this visit. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report given.the state’s words, verbatim · CDSS document, Aug 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/11/24 at 8:30AM. LPA met with Aida Gatchalian and stated the purpose of todays visit. Administrator certificate expires 10/2/25. The facility is licensed for a capacity of 6 non-ambulatory residents of which 1 maybe bedridden in room #2. Hospice Waiver for 4. There are 0 bedridden and 1 hospice resident at this time. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents during this visit. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 110.0*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 2 staff and 2 resident files during this visit. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report giventhe state’s words, verbatim · CDSS document, Sep 11, 2024

Type of visit: Required - 1 Year

On 9/28/23 at approximately 9:40am Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Ma Magnolia Tolon and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility has 6 bedrooms and 3 bathrooms for resident use. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 6 non ambulatory residents. LPA observed the window in the common tv area was missing its screen. Facility Observation: Upon entry the residents were watching tv in their rooms, sitting at the kitchen table visiting and looking at advertisement sheets from the newspaper. 1 resident was in isolation due to covid (day 5, testing negative.) During this inspection 6of 6 resident files and 2 of 6 staffing files were reviewed for regulatory compliance. Staff files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility has 1 resident with 1/2 bedrails and physician orders in place. LPA noted one resident with dementia could not safely manage personal grooming and hygiene items. LPA observed personal hygiene items throughout the residence including but not limited to resident rooms, bathrooms and common areas. Water temperature in common bathroom reads 117.1*F which is within the regulated temperature range of 105*F to 120*. Temperature on the heating and air unit read 73*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were tested and in working order. Fire extinguisher was checked 9/8/23. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. Facility’s liability insurance is current and up to date per regulatory requirements. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. LPA requested and received updated copies of LIC 308, LIC 500, LIC 309, LIC610E and Liability Insurance. LPA was also provided updated Infection Control Plan for CCLD files. The facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Ma Magnolia Tolon and a copy of the LIC 809 reports, LIC 809-D pages, and Appeals rights were provided.the state’s words, verbatim · CDSS document, Sep 28, 2023