561703776-8-23-2024-29-AS-MARO-D8ER4P-20240823124152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 561703776
Report Date: 08/23/2024
Date Signed: 08/23/2024 12:42:03 PM

Document Has Been Signed on 08/23/2024 12:42 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/ DIRECTOR:	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:	08/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Karla Valdez		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

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Licensing Program Analysts (LPAs), Martha Arroyo and Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 9:00 a.m. Upon arrival, there were two (2) staff and one (1) resident. Three (3) residents were at day program at the time of the visit. LPAs were greeted by facility staff who contacted the facility administrator via telephone. Administrator Karla Valdez arrived at the facility at approximately 09:20 a.m. Entrance interview conducted.

Beginning at 9:21 a.m., the LPAs, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Refrigerator and dry food pantry were checked for proper labels and expiration dates and food labels had expiration dates clearly marked. Knives and sharps were observed in a locked drawer by the gas range. The kitchen faucet was measured for water temperature, and it measured 116. degrees Fahrenheit at 9:25 a.m.

BEDROOMS: There are three (3) total bedrooms in the facility for residents, and they are all designated as shared rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

BATHROOMS: There are two (2) bathrooms for resident use. Bathrooms were observed to be equipped with nonskid surfaces. Starting at 9:31 a.m., the water temperature was measured in both bathrooms, and they measured between 106- and 112-degrees Fahrenheit.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BARNARD FAMILY HOME	FACILITY NUMBER: 561703776
	VISIT DATE: 08/23/2024

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Report Continued from LIC 809...

COMMON AREAS: This includes the living room and dining room areas. LPAs observed common area to be clean and properly furnished at the time of the visit. Fire extinguisher was observed to be fully charged on 07/31/2024. Hardwired combination smoke and carbon monoxide detectors were tested at 9:36 a.m. and all were functional at the time of the visit. No fire clearance concerns were observed.

OUTDOOR (BACKYARD/FRONTYARD): The washer and dryer are in the back yard. Residents are responsible for their own laundry needs; however, staff will assist if needed. Detergents and cleaning solutions were observed in a shed locked and inaccessible. All passageways were observed to be clear of any obstructions. There were no bodies of water noted at the time of the visit. LPAs observed one (1) self-latching gate for emergency use. The front yard is equipped with furniture for resident use.

RECORD REVIEW: LPAs reviewed four (4) Resident Records and four (4) Personnel Records including the current Administrator’s file starting at 9:42 a.m.

Resident files were reviewed 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/IPP. All files were complete.

Personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR/CPI training, and the appropriate yearly training. All records were in order.

The Administrator certificate is valid until 01/06/2026.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2-i home.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BARNARD FAMILY HOME	FACILITY NUMBER: 561703776
	VISIT DATE: 08/23/2024

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Report Continued from LIC 809...

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, LPAs reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last one being a fire drill and conducted on 05/04/2024.

MEDICATION REVIEW: LPAs conducted a medication review. Medications are locked in a filing cabinet in the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit.

During today’s visit, LPAs conducted an interview with one (1) staff member.

No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC809 (FAS) - (06/04)

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