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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220437
Report Date: 12/11/2023
Date Signed: 04/12/2024 09:47:52 AM

Document Has Been Signed on 04/12/2024 09:47 AM - 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 S.ASC, 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: 0DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Mary BallardTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a required annual visit/inspection for the facility. LPA met Administrator Mary Ballard who was informed the reason of the visit. The current census is (5). There were no clients present during the visit. Licensing and COVID signs were posted throughout the facility.

All smoke alarms and carbon monoxide detector were tested and functioning properly. The fire extinguisher was charged; and first aid kit had Licensing requirements. Disaster drills are every (6) mos, the last drill was conducted on June 20 2023 .

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food. Food was labeled and properly stored. Knives, sharp objects and medication are stored in a locked cabinet in the kitchen area.

Bedrooms: There were (3) bedrooms designated for clients' use; (1) room is used for TV. All bedrooms were clean, properly furnished and had appropriate bedding and linens.

Bathrooms: There were two bathrooms designated for clients' use. Both bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was measured at 116.8 degrees Fahrenheit. Cleaning supplies were stored in a locked cabinet in the kitchen.

Common Areas: These included the living room, dining, and TV room. All areas appeared clean and were properly furnished.

Surrounding Grounds: All passageways were free of obstruction. Exit gates were easily accessible.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BALLARD HOME
FACILITY NUMBER: 191220437
VISIT DATE: 12/11/2023
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Resident Records: Client files were reviewed which included admission agreements, medical assessments, personal rights documents, and current appraisals.

Staff Records: Staff files included current CPR and first aid certifications and all staff have criminal record clearance and are associated to this facility.

Medications: No discrepancies observed. Properly labeled medications were locked and secured.

No citations/ Exit Interview Conducted / A Copy of the Report Issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC809 (FAS) - (06/04)
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