565800177-11-7-2024-29-AS-EMOY-DASTEC-20241107133943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800177
Report Date: 11/07/2024
Date Signed: 11/07/2024 01:40:45 PM

Document Has Been Signed on 11/07/2024 01:40 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 HOME		FACILITY NUMBER:	565800177
ADMINISTRATOR/ DIRECTOR:	BONITA BALLARD 98		FACILITY TYPE:	735
ADDRESS:	1226 WEST RODERICK STREET		TELEPHONE:	(805) 988-4054
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY: 6		CENSUS: 6	DATE:	11/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Melinda Walker - Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:35 a.m. Upon arrival, LPA Mosley was greeted by staff and informed them to call the Administrator. The LPA met with Administrator Melinda Walker and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and freezer were inspected. Food labels were inspected and checked for dates and expiration dates. Food had labels clearly marked with dates. Knives and sharps were observed locked in a drawer. Cleaning supplies and items that could pose a danger were secured in locked cabinets. The hot water temperature was measured at 106.3 F at 10:02 a.m. which is within the required range.

Report Continued on LIC 809C 2nd Page

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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 ADULT SUPPORTIVE LIVING HOME	FACILITY NUMBER: 565800177
	VISIT DATE: 11/07/2024

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Report Continued from LIC 809... (2nd Page)
COMMON SPACES/ BACKYARD: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture appear to be in good condition. The fire extinguishers appeared to be fully charged and were last inspected 04/25/2024. The smoke and carbon monoxide detectors were tested at 9:51 a.m. and functioned properly during the visit. The last emergency disaster drill took place on 10/30/2024 and conducted quarterly. Activities were observed in the common areas. There is a washer and dryer on the premises. Laundry soap is stored in a locked cabinet. The facility has a sufficient supply of emergency food and water located in the supply room in the back yard. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.
RESTROOM: The facility has two (2) restrooms. One (1) is designated as private client restrooms, one (1) is designated as a shared restroom. All client restrooms were clean and sanitary with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature in all restrooms were measured between 9:45 a.m. – 10:00 a.m. and measured between 105.3 F- 106.7 F, all within the required range.

BEDROOMS: There are four (4) client bedrooms; two (2) are designated as private, single occupancy bedrooms and two (2) are designated as a shared double-occupancy bedroom. LPA observed all client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

MEDICATIONS: Medications review began at approximately 11:33 a.m. The medications are locked in a cabinet adjacent to the kitchen in a medication box. Medications for six (6) clients were reviewed. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records.

Report Continued on LIC 809C 3rd Page

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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 ADULT SUPPORTIVE LIVING HOME	FACILITY NUMBER: 565800177
	VISIT DATE: 11/07/2024

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Report Continued from LIC 809C 2nd Page... (3rd Page)

RECORDS:

CLIENT RECORDS: were reviewed beginning at 10:05 a.m. for six (6) clients. Files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order at the time of the visit.

PERSONNEL FILES: were reviewed beginning at 11:02 a.m. for three (3) staff including the Administrator. Files were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order at the time of the visit.

P&I Money: at 11:27a.m. the LPA and staff reviewed all six (6) clients who have their cash resources save guarded by the facility. Cash resources were found to be separate and intact and not commingled with facility funds or petty cash.

INTERVIEWS: One (1) staff interview was conducted. One (1) client interview was attempted during the inspection.

During today’s visit, the LPA obtained copies of the following: Staff schedule, LIC 9020 Resident Roster, current liability insurance, and Surety Bond.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

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