561703776-8-18-2023-29-AS-MARO-CUTTP3-20230818145337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 561703776
Report Date: 08/18/2023
Date Signed: 08/18/2023 02:53:52 PM

Document Has Been Signed on 08/18/2023 02:53 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BARNARD FAMILY HOME		FACILITY NUMBER:	561703776
ADMINISTRATOR:	KARLA IBARRA		FACILITY TYPE:	735
ADDRESS:	4780 BARNARD STREET		TELEPHONE:	(805) 526-0043
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 6		CENSUS: 4	DATE:	08/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Karla Ibarra		TIME COMPLETED:	03:10 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) Martha Arroyo arrived unannounced to conduct a one year required annual visit at 8:30 a.m. The last annual conducted at this facility was on 08/29/2022. Upon arrival, the LPA was greeted at the door by staff. The Administrator, Karla Ibarra arrived shortly after and the reason for the visit was explained. Entrance interview conducted.

At 9:00 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The LPA inspected the kitchen and food area at 9:15 a.m. Knives and sharps were observed in a locked drawer next to the oven. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 9:17 a.m., the hot water temperature was measured in the kitchen at 117.6 degrees Fahrenheit.

Common areas: Living and dining room furniture were observed to be in good condition. At 9:05 a.m., smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The LPA observed required postings throughout the common space. The fire extinguisher was observed to be charged and last serviced on 08/04/2023.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BARNARD FAMILY HOME	FACILITY NUMBER: 561703776
	VISIT DATE: 08/18/2023

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
26
27
28
29
30
31
32

(Report Continued from LIC 809...)

Outdoor: The washer and dryer are in the back yard. Clients are responsible for their own laundry needs; however, staff will assist if needed. Cleaning supplies and disinfectants are stored in a locked shed in the backyard. The backyard has a covered outdoor area equipped with furniture for client use. The LPA observed one side gate that is self-closing and latched. Passageways were observed clear of obstructions in case of an emergency. No bodies of water noted at the time of visit.

Restrooms: The two client restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature was measured in both restrooms; the first bathroom measured at 111.7 degrees Fahrenheit at 9:04 a.m.; and the second bathroom measured at 110.3 degrees Fahrenheit at 9:07 a.m.

Bedrooms: There are three (3) shared client rooms, which were furnished with appropriate linens and required furniture. Adequate lighting in all bedrooms was observed.

Records: The LPA reviewed client records at 9:23 a.m. and personnel records at 10:43 a.m. The LPA reviewed four (4) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Three (3) out of four (4) clients did not have a copy of the admissions agreement; however, the Administrator printed a copy and placed on each client’s file at the time of the visit. All client files were in order.

At 10:21 a.m., record review revealed that Client #1’s (C1’s) Physicians Report dated 05/16/2023 indicates C1 has no capacity for self-care and requires 24-hour monitoring. The Administrator stated the facility is able to care for C1’s care needs and will be submitting an exception request to retain C1 as C1 does not requires nursing care.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BARNARD FAMILY HOME	FACILITY NUMBER: 561703776
	VISIT DATE: 08/18/2023

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
26
27
28
29
30
31
32

(Report Continued from LIC 809C...)

Three (3) personnel files and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2-i home. The last disaster drill was conducted on 05/21/2023.

Medications: Medications review began at 12:15 p.m.; medications are centrally stored and locked in a file cabinet adjacent to the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medication and destruction record. No errors observed during medication review.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 08/18/2023 02:53 PM - It Cannot Be Edited

Created By: Martha Arroyo On 08/18/2023 at 01:56 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BARNARD FAMILY HOME	FACILITY NUMBER: 561703776
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80091(a)(3)

Prohibited Health Conditions

(a) In adult CCFs clients who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained. (3) Conditions that require 24-hour nursing care and/or monitoring. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review and interview conducted, the licensee did not comply with the section cited above as C1 has no capacity for self-care and requires 24 hour monitoring, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2023
	Plan of Correction
1 2 3 4	The Administrator will be submitting an exception request to retain C1 in the facility to CCL by 08/25/2023. .

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Desaree Perera

LICENSING EVALUATOR NAME:

Martha Arroyo

LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6