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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803476
Report Date: 12/04/2023
Date Signed: 12/04/2023 01:33:54 PM

Document Has Been Signed on 12/04/2023 01:33 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 HOME #4FACILITY NUMBER:
197803476
ADMINISTRATOR:MARY BALLARDFACILITY TYPE:
735
ADDRESS:62 W. HARRIET STREETTELEPHONE:
(626) 794-2842
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 2DATE:
12/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mary BallardTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Mary Ballard and informed her the reason of the visit; which is to a conduct an annual inspection. Facility is Licensed to retain 4 ambulatory and 2 non-ambulatory clients with the Level Four intellectual disabilities. The current census is (6); but during the visit, there were (2) clients present.

The following was observed during the inspection: Kitchen: LPA observed Licensing requirement of (7) day nonperishable, and (2) perishable, with extra refrigerator stocked with food. Food was properly wrapped, and appliances were functional, clean, and in good repair. Chemicals, household supplies, and knives, were locked and secured. Living/dining/family: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for client's comfort. Bedrooms: The facility has (4) bedrooms; with (2) rooms are shared; and (2) private rooms. There (1) room used for staff office. Client rooms have appropriate lighting, furniture, bedding, and linens. There are sufficient linens observed and available. Personal hygiene products are available for client's use. Bathrooms: There are (3); all were clean, with soap and towels. Hot water measured at 111.4 degrees Fahrenheit. Surrounding Grounds: There were no visible hazards; passageways were free from obstruction and gates were easily accessible to open. The backyard has outdoor furniture with a covered shaded area for clients. There is no body of water at the facility. Fire extinguisher fully charged. First aid kit furnished fully equipped. Smoke alarms and carbon monoxide detectors are functioning. The facility has a sufficient supply of PPE. 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 clients.

Medications- LPA observed medication to be locked and inaccessible to clients. There were no medication errors. Record review: A complete record review of staff and clients were conducted; all required documents were in files, including training and client medical assessments. All staff and clients are vaccinated. No citation issued; exit interview and copy of report provided.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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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