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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290263
Report Date: 12/02/2024
Date Signed: 12/02/2024 04:10:26 PM

Document Has Been Signed on 12/02/2024 04:10 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BALLARD HOMEFACILITY NUMBER:
191290263
ADMINISTRATOR/
DIRECTOR:
MILES BALLARDFACILITY TYPE:
735
ADDRESS:3231 NORTH GRANDEUR AVENUETELEPHONE:
(626) 794-2620
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 8CENSUS: 7DATE:
12/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Co-Administrator, DL M. BallardTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted a Required One (1) year annual visit and inspection. LPA met with Co-Administrator and Direct Support Professional (DSP), Angelica Campos gained entry, explained the reason for the visit.

At 10:25a.m., Co-Administrator and LPA conducted physical plant tour inside and outside. Required posting observed in facility in the hallway. The smoke alarms are operational that are located in each bedroom, hallway and command areas. There are carbon monoxide detectors that functions properly. The fire extinguishers are located in the kitchen, front and back hallway. The charge date is 04/09/2024. During the visit the facility is at 73 degrees Fahrenheit.

The facility is licensed for an Adult Residential Facility, capacity of two (02) non ambulatory and six (06) ambulatory developmentally disabled clients. Facility is vendor through San Gabriel Pomona Regional Center as level 4E home. Facility has four (04) bedrooms and two (02) bathrooms for clients and staff. There are two (02) rooms upstairs locked at all times that are used for storage and staff office. The facility is a two-story home that in a residential community. There is no body of water in the facility. Fire and Earthquake Disaster drill was last conducted on 11/12/2024. Four (04) clients are at Day Program and three (03) clients at the facility waiting for a physician to visit them.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA observed at least two (02) days perishable and seven (07)

Continue to LIC 809

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BALLARD HOME
FACILITY NUMBER: 191290263
VISIT DATE: 12/02/2024
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days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked box in the kitchen cabinet. The menu was posted on the side of refrigerator for review Adult Residential Facility (ARF), snacks and beverages are available at all times to clients. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, detergents, pesticides or toxic cleaning supplies were stored and locked in cabinet next to laundry room. Laundry room is located adjacent to the kitchen. Bedrooms: There are four (04) shared bedrooms designated for clients' use. They were toured and observed to be clean and properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bathrooms: Were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at a range of 105.4°F to 107.4°F and within the required range. Client’s personal hygiene supplied are kept in traveling bags label with their name in a locked shelf outside the bathroom. The two (02) bathrooms in the facility are designated for client's and staff use. Towels and washcloths are not shared. The bathrooms were properly supplied and had functional fixtures. There was enough clean linen available in hallway cabinets. Common Areas: These included the living room and dining area for clients. The common areas were properly furnished and observed to be in good repair. No obstructions and or tripping hazards throughout the facility. Clients dining table fits eight (08) clients. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Staff Files: Staff records were reviewed, they all have criminal record clearances and associated to this facility. Staff have current first aid and training documentation showing training completed. Administrator's and Co-Administrator's certificate was observed to be current. Medications are in a centrally stored, locked cabinet, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ physician. Proper medication dispensing instruction are followed and checked for contamination. First-aid kit has all proper items and is current. Client records All seven (07) client records were reviewed. Client records are complete and current at this time. Cash resources, personal property and valuables are kept in separate envelop account and not co-mingled with facility funds. LPA reviewed client logs and envelop account.

No deficiencies cited during the visit.

Exit interview conducted and a copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024
LIC809 (FAS) - (06/04)
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