<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800177
Report Date: 11/03/2023
Date Signed: 11/03/2023 03:51:33 PM

Document Has Been Signed on 11/03/2023 03:51 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 ADULT SUPPORTIVE LIVING HOMEFACILITY NUMBER:
565800177
ADMINISTRATOR:BONITA BALLARD 98FACILITY TYPE:
735
ADDRESS:1226 WEST RODERICK STREETTELEPHONE:
(805) 988-4054
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 6DATE:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Melinda WalkerTIME COMPLETED:
03:58 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 co-administrator Melinda Walker at 1:04 p.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.

BEDROOMS: There are a total of four client bedrooms; two shared and two single rooms. All client bedrooms were clean, appropriately furnished and had sufficient lighting. There is no staff room; the facility has 24/7 awake staff.

RESTROOMS: There are two (2) total bathrooms at the facility. One bathroom is a jack and jill bathroom shared between two bedrooms and one bathroom is located in the hallway. They have showers with non-skid materials. The toilets and showers have grab bars. The hot water temperature was tested in the hall bathroom; the hot water temperature measured 108.9*F which is within the regulatory range of 105*-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. 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 are stored in the locked storage room and locked 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)
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BALLARD ADULT SUPPORTIVE LIVING HOME
FACILITY NUMBER: 565800177
VISIT DATE: 11/03/2023
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
(continued from 809)


KITCHEN: The kitchen was clean and appliances appear to be operable. Knives and cleaning supplies are stored in a locked drawer and cabinet 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 refrigerator in the supply room 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: All clients were at their day programs or in the community. There were no staff except the administrator at the facility. LPA reviewed two client files and two staff files; files were complete. LPA reviewed medications which appear to be given as prescribed.

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)
Page: 2 of 2