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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220437
Report Date: 12/21/2024
Date Signed: 12/21/2024 12:15:31 PM

Document Has Been Signed on 12/21/2024 12:15 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BALLARD HOMEFACILITY NUMBER:
191220437
ADMINISTRATOR/
DIRECTOR:		BALLARD, MARYFACILITY TYPE:
735
ADDRESS:142 WEST MENDOCINO AVENUETELEPHONE:
(626) 794-8738
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 5DATE:
12/21/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Al Ballard - House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA met with House Manager Al Ballard. Purpose of the visit is stated. This is a San Gabriel Pomona Regional Center vendored facility Level IV-C.

LPA conducted physical plant tour inside and out at 9:20 AM. During the tour, LPA observed that the facility has three (3) bedrooms and two (2) bathrooms. One (1) bedroom is designated for staff use. There is no body of water in the facility. This facility is fire cleared for six (6) ambulatory residents only.

The front main door is the only entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

The facility had submitted and approved Mitigation and Infection Plan.

The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage.

Bedrooms were toured and observed to be clean and appropriately furnished.
Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at a range of 118.7°F to 119.8°F.
Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2024
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: 12/21/2024
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(continued from LIC 809)

Kitchen area is observed to be clean and sanitary. All disinfectants, cleaning solutions and other toxins were observed to be locked in a kitchen cabinet. Knives and other sharps were also locked in the same cabinet. Laundry area is located adjacent to the kitchen. Laundry detergent and other toxins are kept in the locked kitchen cabinet.
Food. The facility is observed to have sufficient food supply both perishable and non-perishable for clients. Temperature of facility wall thermostat was set at 74.0°F and observed to be within the required range.
Fire extinguishers were observed to be located in the living area. There are two (2) Fire extinguishers, one is located in the living room and the other on the bedroom hallway. Fire extinguishers were observed to be operable and last inspected on 01/09/24 . Fire alarms are battery operated and observed to be operational. There is carbon monoxide detector installed in the facility located in bedroom hallway..
Medication were observed to be locked, inaccessible and stored in a cabinet in the bedroom hallway near the staff room/lounge. There was a complete first aid kit located in the medication cabinet.
Garage is detached to the facility and converted into a living staff quarter. Half of the garage is also used as an office. The garage was observed to be locked during visit.

Client records. All five (5) client records were reviewed. Clients record are complete and current.
Staff records were also reviewed. All staff present records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 11/25/24. Required posting observed in facility (complaint hot line poster, personal rights, etc). There was no health and safety hazard observed during the day of inspection.

Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2024
LIC809 (FAS) - (06/04)
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