565800034-11-3-2023-29-AS-TCAA-CX8QQH-20231103122222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800034
Report Date: 11/03/2023
Date Signed: 11/03/2023 12:23:01 PM

Document Has Been Signed on 11/03/2023 12:23 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BALLARD FAMILY HOME		FACILITY NUMBER:	565800034
ADMINISTRATOR:	BONITA BALLARD 98		FACILITY TYPE:	735
ADDRESS:	1611 BROOKSIDE AVENUE		TELEPHONE:	(805) 985-6493
CITY:	OXNARD	STATE: CA	ZIP CODE:	93035
CAPACITY: 6		CENSUS: 6	DATE:	11/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Morris Pippins		TIME COMPLETED:	12:25 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) Teresa Camara conducted an unannounced required annual visit to the facility. LPA met with the staff member at 9:20 a.m. and explained the reason for the visit. LPA toured the physical plant areas inside and outside to ensure that there are no health and safety hazards. The co-administrator Morris Pippins arrived at the facility at 9:50 a.m. BEDROOMS: There are a total of 3 shared client bedrooms. All client bedrooms were clean, appropriately furnished and had sufficient lighting. There is one room set up as an office/staff room. This facility has 24/7 awake staff. RESTROOMS: There are two (2) total bathrooms at the facility. Both can be used by clients. The resident bathrooms have a shower with non-skid materials. The toilet and showers have grab bars. The hot water temperature was tested in the hall bathroom which is the bathroom primarily used by clients; the hot water temperature measured 115.6F which is within the regulatory range of 105-120F. COMMON SPACES:* In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. There is a large chair which blocks the fireplace in the living room. The administrator stated the fireplace is not used. LPA informed the administrator the fireplace should have a screen on it; the administrator will purchase a screen for the fireplace within a week. The outdoor area is equipped with furniture for clients' use. LPA observed the required postings throughout the facility. The fire extinguisher appeared fully charged and was last serviced on 5/30/2023. The smoke detectors and carbon monoxide detector were tested and functioned properly during the visit. There were no bodies of water noted. Cleaning chemicals and laundry supplies are stored in a locked cabinet in the garage. (continued on 809-C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: BALLARD FAMILY HOME	FACILITY NUMBER: 565800034
	VISIT DATE: 11/03/2023

NARRATIVE

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(continued from 809)

KITCHEN: The kitchen was clean and appliances appear to be operable. Knives are stored in a locked box in the kitchen. The supply of perishable and nonperishable food is adequate. There is an emergency supply of food and water in the garage. There is a freezer in the garage with more perishable food. No flies or other vermin were observed.

INFECTION CONTROL: LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

RECORD REVIEW/INTERVIEWS: Four clients were at their day programs. Two clients were at the facility but both of the clients are non-verbal. There were two staff at the facility; LPA interviewed both staff. LPA reviewed two client files which were complete. LPA reviewed two staff files which were complete. LPA reviewed medications which appear to be given as prescribed and the the centrally stored medication and destruction records were completed correctly.

No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

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