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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800177
Report Date: 11/16/2022
Date Signed: 11/17/2022 08:03:00 AM

Document Has Been Signed on 11/17/2022 08:03 AM - 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:BALLARD ADULT SUPPORTIVE LIVING HOMEFACILITY NUMBER:
565800177
ADMINISTRATOR:BONITA BALLARD 98FACILITY TYPE:
735
ADDRESS:1226 WEST RODERICK STREETTELEPHONE:
8059884054
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 6DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Belinda WalkerTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced required annual visit
to the facility above. LPA Ascencio met with the Administrator Belinda Walker and explained the reason for the visit. At 03:35 p.m., the LPA, along with the Admin toured the physical plant areas inside and outside to ensure that there are no health and safety hazards.

BEDROOMS: All client rooms are set up with beds, nightstands, lamps, chests of drawers,
chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean
linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a
bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for
easy passage between the beds. In addition, no bedroom was used as a passageway to another
room, bath or toilet. There are four (4) total bedrooms: two (2) rooms are shared and 2 are private.

RESTROOMS: There are two (2) total bathrooms at the facility. Both are for client use. The client bathroom have a shower with non-skid materials. The toilet and showers have grab bars. The hot water temperature was tested in the bathrooms and kitchen. Areas were found to be within the range of 105*F and 120*F.

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. Chairs were observed to be at least 6 (six) feet apart for social
distancing. The LPA observed the required postings in the common hallway. The fire extinguisher was
observed to be serviced within the last year.

Continued on LIC 809 – C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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 2
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: BALLARD ADULT SUPPORTIVE LIVING HOME
FACILITY NUMBER: 565800177
VISIT DATE: 11/16/2022
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The facilities smoke detectors and carbon monoxide alarms were tested throughout the facility and seemed to work properly at the time of visit. Medication was observed to be locked and contained 30 days of medication. The garage was observed locked contained laundry supplies, emergency food supply and other cleaning supplies. The outdoor patio has a covered outdoor area equipped with furniture for client use. There were no bodies of water noted.

KITCHEN: Kitchen knives are stored in the locked, cabinet in the kitchen. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the
refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is adequate. There are
no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils.
Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids.
Kitchen, laundry and house cleaning supplies are stored in a locked cabinet in the kitchen. No flies or other vermin were observed.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Admin regarding the
facility’s infection control practices at 4:00 p.m. There is 1 entry into the facility. Upon entry, the
facility has a central entry point for symptom screening. The LPA noted that the facility is allowing
visitors for both indoor and outdoor visitation. The 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.

No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided via
email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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