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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220437
Report Date: 05/18/2022
Date Signed: 05/18/2022 04:50:10 PM

Document Has Been Signed on 05/18/2022 04:50 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BALLARD HOMEFACILITY NUMBER:
191220437
ADMINISTRATOR:BALLARD, MARYFACILITY TYPE:
735
ADDRESS:142 WEST MENDOCINO AVENUETELEPHONE:
(626) 794-8738
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 6DATE:
05/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Mary Ballard, AdministratorTIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced annual required visit at the facility. LPA was greeted by staff, and briefly toured the premises. LPA Valenzuela met with Administrator Mary Ballard. The purpose of the visit was discussed.

The required Covid-19 posters are posted throughout the facility. Staff and clients were observed to being wearing masks.

The facility is licensed for an Adult Residential Facility, capacity of 6 ambulatory clients. Facility is vendorized through San Gabriel Pomona Regional Center as a level 4C home. The facility is a single story, 4 bedroom home; three rooms are for clients and one for staff. Water temperature was measured at 119.0 degrees F, all smoke detectors were operable and fire extinguishers were last serviced in January of 2022. A comfortable temperature of 76 degrees F. is maintained in the facility. There are no bodies of water, and LPA did not observe any accessible hazards.

LPA observed the kitchen to be clean and sanitary, and an adequate supply of perishable and non-perishable foods to be properly stored on site. Client rooms and bathrooms were adequately lit and furnished, all appeared to be sanitary and well-kept. All indoor and outdoor passageways were free of obstruction, and an adequate supply of spare linens and hygienic supplies is present.

There is one complete first aid kit. Medication is stored in the staff room, which is kept locked and inaccessible to clients.

No deficiencies noted. Exit interview conducted. Signature obtained .
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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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