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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800034
Report Date: 11/04/2024
Date Signed: 11/04/2024 01:46:01 PM

Document Has Been Signed on 11/04/2024 01:46 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 HOMEFACILITY NUMBER:
565800034
ADMINISTRATOR/
DIRECTOR:
BONITA BALLARD 98FACILITY TYPE:
735
ADDRESS:1611 BROOKSIDE AVENUETELEPHONE:
(805) 985-6493
CITY:OXNARDSTATE: CAZIP CODE:
93035
CAPACITY: 6CENSUS: 6DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Morris Pippins-Co-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced required annual visit
to the facility. LPA met with Co-Administrator Morris Pippins at 10:15 a.m. and explained the reason for the visit. When the LPA arrived, there were two (2) staff and one (1) client present.

At 10:28 a,m. the LPA and Administrator conducted a tour of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of three (3) clients bedrooms, one (1) office/staff room, and two (2) bathrooms. The home is vendored by Tri-Counties Regional Center as a level 4-H home. The LPA observed a fire extinguisher at the facility, which was fully charged and last serviced 04/25/2024. All smoke alarms and carbon monoxide detectors were tested and operable. LPA observed all required postings throughout the facility.

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.

BEDROOMS: All client bedrooms were clean, appropriately furnished and had sufficient lighting. 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 114.4*F which is within the regulatory range of 105*-120*F.
Report will continue on LIC809-C, 2nd page.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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 4
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: 11/04/2024
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(continued from 809)

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. The fireplace in the living room was properly screened. The outdoor area is equipped with furniture for clients' use. There were no bodies of water noted. Cleaning chemicals and laundry supplies are stored in a locked cabinet in the garage.

RECORD REVIEW: At 10:45 a.m., a review of facility files was initiated. Facility records are stored in the office room and hallway closet. The LPA observed documentation of Infection Control, and last Disaster drill (conducted on 08/22/2024). The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five(5) out of six (6) client files and five (5) out of fifteen (15) staff files. The home did not have an updated Emergency and Disaster Plan, otherwise all documents reviewed appeared complete and current. The LPA advised the Administrator client files should be locked to ensure their privacy.

Medications: Medications review began at 11:39 a.m. The LPA reviewed medications for two (2) clients. Medications are centrally stored and locked in locked boxes in a the kitchen cabinet; medications are labeled and checked for expiration dates. Medications are documented on the centrally stored medications and destruction record (CSMDR). Expiration dates on the medication bubble packs did not match the expiration dates on the CSMDR, however the CSMDR's are generated and provided by the pharmacy. The LPA discussed best practices with the Administrator to always review and correct CSMDR that's provided by the pharmacy to ensure it's accurate. During C2's audit, the LPA observed two (2) medications indicated as noon medications in the prescription label, however at noon the medications were still in the pack, and the client is currently at day program. Upon observation, the Administrator stated that the medications are given at 2 p.m. The administrator called the pharmacy tech who advised the LPA that the medications are able to be given at 2pm without any concern.

Interviews: Five (5) out of six (6) clients were at their day program. The client at the facility is non-verbal. The LPA interviewed two (2) staff. There were no concerns voiced.

No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
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