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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801459
Report Date: 11/22/2022
Date Signed: 11/22/2022 01:51:53 PM

Document Has Been Signed on 11/22/2022 01:51 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:IBARRA FAMILY HOME #2FACILITY NUMBER:
565801459
ADMINISTRATOR:KARLA IBARRAFACILITY TYPE:
735
ADDRESS:5664 KATHERINE STREETTELEPHONE:
(805) 210-2784
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 5DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sarah McGary, StaffTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced required annual visit. At 12:44 p.m., the LPA was greeted and screened by staff. At 12:47 p.m., the LPA spoke with the Administrator over the phone. The Administrator was not available during today’s visit and authorized staff, Sarah McGary to sign the report. When the LPA arrived, there was one staff and all the clients were at day program. This home is vendored by Tri-Counties Regional Center as a level 2.

This annual had a specific emphasis on infection control practices and procedures. At 12:58 p.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

BEDROOMS: There are four (4) client bedrooms and one (1) staff room. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 1:02 p.m., the hot water temperature tested at 109.4-degree Fahrenheit.

COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the fire extinguisher to be fully charged and last serviced on 08/06/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 1:05 p.m., fire alarms and carbon monoxide detectors were tested and functioning properly. Medications are centrally stored and in a locked filing cabinet near the living room. Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: IBARRA FAMILY HOME #2
FACILITY NUMBER: 565801459
VISIT DATE: 11/22/2022
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KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:13 p.m., hot water measured at 108.0-degree Fahrenheit.

OUTDOOR SPACE: At 1:10 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a self-latching gate designated for an emergency exit.

GARAGE: The garage is attached to the house. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage. The laundry units are located inside the garage.

INFECTION CONTROL: During today’s visit, the LPA spoke with staff regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed a 30-day supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient.

No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report will be provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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