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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290263
Report Date: 12/02/2025
Date Signed: 12/02/2025 03:12:58 PM

Document Has Been Signed on 12/02/2025 03:12 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:
12/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Admin., Mills Ballard, Co-Admin., DL M. Ballard & Direct Support Professional (DSP), Angelica Campos CortezTIME VISIT/
INSPECTION COMPLETED:
03:30 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 Administrator, Co-Administrator and Direct Support Professional (DSP). LPA was granted entry by DSP and explained the purpose of the visit upon arrival.

At approximately 10:15a.m., Co-Administrator and LPA conducted physical plant tour inside and outside. Required posting observed in facility hallway. The smoke alarms are operational and located in each bedroom, hallway and command areas. Carbon monoxide detectors were present and functioning properly. Fire extinguishers were observed in the kitchen area and hallway with current service tagging dated 03/09/2025. Facility temperature measured 74 degrees Fahrenheit at the time of inspection.

The facility is licensed for an Adult Residential Facility(ARF), capacity of two (02) non ambulatory and six (06) ambulatory developmentally disabled clients. Facility is vendor through San Gabriel Pomona Regional Center as level 4 home. Facility has four (04) bedrooms and two (02) bathrooms for clients and staff. Upstairs area is a bedroom/office for administrator use only and always locked. The facility is a two-story home located in a residential community. There is no body of water in the facility. Fire and Earthquake Disaster drill was last conducted on 11/09/2025. During the visit, three (03) clients were present, and four (04) additional clients were attending Day Program site.

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 electric stove, faucet, freezer, refrigerator, and microwave -were operational and maintained in safe condition. LPA observed at least two (02) days perishable and seven (07)

Cont. to LIC 809

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 12/02/2025
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Cont. from LIC 809

days non-perishable food at the facility that is properly stored. Frozen foods are wrapped, dated, and stored properly as well. Knives were stored in a locked box in the kitchen cabinet. Menus as well as ARF snacks and beverages, were posted for client and staff review. Food preparation and storage areas were clean and free from visible pest activity. Garbage containers were covered with tight fitting lids. Cleaning agents, detergents, and other toxic cleaning supplies were stored and were locked and separated from food items. Laundry room is located adjacent to the kitchen. Bedrooms: There are four (04) share bedrooms designated for clients' use. They were toured and observed to be clean and properly furnished with appropriate dresser, bedding, and linens with sufficient lighting. No tripping hazards were present. Bathrooms: The facility contains two (02) full bathrooms designated for both clients and staff. Hot water temperature measured at a range of 108.1°F to 114.1°F within the required range. Bathrooms contained sufficient hygiene supplies, towels, and clean linens, stored securely in hallway cabinets. Linens appeared clean and in good repair. The bathrooms had functional fixtures. Common Areas: The living room, dining area, and all common spaces were appropriately furnished, maintained, accessible, and free from obstructions or hazards. Exits and entryways were clear. Outdoor areas included suitable furniture for client recreation. No safety barriers or hazards were observed. Staff Records: Staff files were reviewed. All personnel maintained valid criminal background clearances, completed required training, and current certification in CPR and First Aid. Administrator and Co-Administrator certificates were verified and current. Training documentation for staff was complete. Client Records: Client files were reviewed. All client records are complete and current. Medication logs were reviewed. Centrally stored prescription and PRN medications were maintained locked, properly labeled and supported by physician documentation. Medication was logged consistently with physician orders. LPA reviewed clients cash envelopes used for client valuables, petty cash resources were kept separate and not intermingled with facility funding. A current, complete First-Aid kit was present.

No deficiencies cited during the visit.

Exit interview conducted and a copy of this report issued.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC809 (FAS) - (06/04)
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