565800034-11-6-2025-29-AS-ECOZ-DN6W5K-20251106155917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800034
Report Date: 11/06/2025
Date Signed: 11/06/2025 04:00:33 PM

Document Has Been Signed on 11/06/2025 04:00 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/ DIRECTOR:	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:	11/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Co-Administrator Morris Pippins		TIME VISIT/ INSPECTION COMPLETED:	04:00 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) Esther Cortez conducted an unannounced required annual visit to the facility. LPA met with Co-Administrator Morris Pippins at 09:20 a.m. and explained the reason for the visit. When the LPA arrived, there were three (3) staff and two (2) clients present. RECORD REVIEW: At 09:45 a.m., a review of facility files was initiated. Facility records are stored in the locked hallway closet. The LPA observed documentation of Infection Control, Emergency Disaster Plan and last Disaster drill (conducted on 10/01/2025). LPA advised disaster drills need to be conducted every shift. The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five(5) out of six (6) client files and five (5) staff files. All client and staff files were complete and current. 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 04/02/2025. 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. Report will continue on LIC809-C, 2ND PAGE.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025

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

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BALLARD FAMILY HOME	FACILITY NUMBER: 565800034
	VISIT DATE: 11/06/2025

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

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.

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.

Medications: 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). Date filled, start dates, and expiration dates on the medication bubble packs did not match 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 or document their own CSMDR.

Interviews: The LPA interviewed one (1) client and two (2) staff. Concerns voiced by client were addressed with the Administrator. Administrator revealed that there had been allegations/incidents reported that were not reported to licensing. Additionally, the Administrator showed the LPA a book of incident logs that were documented but not reported to licensing.

The following deficiencies were cited from the CA Code of Regulations and/or Health and Safety Code.. (See LIC 809-D). Exit interview and reported reviewed with the Co-Administrator. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 11/06/2025 04:00 PM - It Cannot Be Edited

Created By: Esther Cortez On 11/06/2025 at 03:29 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: BALLARD FAMILY HOME	FACILITY NUMBER: 565800034
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80061(1)(E-G)

80061 (1) (E-G) Reporting Requirements (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. (F)Any suspected psychological abuse of any client. (G) Any suspected physical abuse of any minor. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in alleged incidents that were reported to the administrator by staff and not reported to Licensisng which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/14/2025
	Plan of Correction
1 2 3 4	Licensee agree to conduct reporting requirement training for all staff.. Submit proof of training to CCL by 11/14/2025.

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.

	Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:

	Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025

LIC809 (FAS) - (06/04)

Page: 6 of 6