197803476-1-6-2022-31-AS-RVAA-CAF2AD-20220106161321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803476
Report Date: 01/06/2022
Date Signed: 01/06/2022 04:13:28 PM

Document Has Been Signed on 01/06/2022 04:13 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 HOME #4		FACILITY NUMBER:	197803476
ADMINISTRATOR:	MARY BALLARD		FACILITY TYPE:	735
ADDRESS:	62 W. HARRIET STREET		TELEPHONE:	(626) 794-2842
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY: 6		CENSUS: 5	DATE:	01/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Mary Ballard, Administrator		TIME COMPLETED:	04:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required One (1) year Infection Control inspection to the facility. LPA met with Administrator Mary Ballard and explained the reason for the visit. A tour of the physical plant was conducted at 1:40 pm and the following was noted: There is only one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves, and masks are available. LPA was screened upon entry. The facility had submitted and approved Mitigation Plan. Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted throughout the facility. The facility has a designated visitors' area in the backyard. The facility has sufficient stock of PPE in the storage room. The facility has four (4) bedrooms and three (3) bathrooms currently occupying five (05) residents. Two (02) rooms are shared rooms. One room is for staff. (continued on LIC 809-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BALLARD HOME #4	FACILITY NUMBER: 197803476
	VISIT DATE: 01/06/2022

NARRATIVE

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Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 76 degrees. The smoke detectors are observed to be operational. There is a carbon monoxide detector in the facility. Fire extinguishers were last serviced January 2022.

The backyard of the facility has outdoor furniture with a covered shaded area for residents. There is no body of water at the facility.

Laundry area is located by the kitchen, laundry detergents, cleaning agents and other toxins are stored in a cabinet which was observed to be locked and inaccessible to residents.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit.

The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured at 111.4 degrees. There was enough clean linen available in stock in the closets.

Medications-LPA observed medication to be locked and inaccessible to residents. There are two (02) complete first aid kits.

Exit interview conducted. A copy of this report was issued and signature obtained.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

LIC809 (FAS) - (06/04)

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