565801459-12-19-2024-29-AS-MARO-DC4THS-20241219134512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801459
Report Date: 12/19/2024
Date Signed: 12/19/2024 01:45:27 PM

Document Has Been Signed on 12/19/2024 01:45 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 #2		FACILITY NUMBER:	565801459
ADMINISTRATOR/ DIRECTOR:	KARLA IBARRA		FACILITY TYPE:	735
ADDRESS:	5664 KATHERINE STREET		TELEPHONE:	(805) 210-2784
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 6		CENSUS: 5	DATE:	12/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Karla Valdez		TIME VISIT/ INSPECTION COMPLETED:	02:00 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) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today at 9:30am. Upon arrival, there was one (1) staff and one (1) resident. Four (4) residents are currently attending community programs. The LPA was greeted by facility staff who contacted the Administrator via telephone. The Administrator, Karla Valdez arrived at approximately 9:45am. Entrance interview conducted.

Starting at 9:47am, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food; properly stored. Refrigerator and dry food pantry were checked for proper labels and expiration dates. Knives and sharps were observed in a locked drawer inaccessible to residents in care.

BEDROOMS: There are four (4) bedrooms for resident use and one (1) bedroom designated for staff. One (1) bedroom is designated as double occupancy; and three (3) bedrooms are designated as single occupancy. The LPA observed all resident bedrooms to be properly furnished with a bed, nightstand, and sufficient lighting. The bedrooms had appropriate and adequate bedding. The LPA observed additional clean linens and towels in the hallway closet.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

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 3

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: 12/19/2024

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

Report Continued from LIC 809...

BATHROOMS: There are two (2) bathrooms for resident use. Bathrooms were observed to be equipped with nonskid surfaces. The LPA observed bathrooms to be clean, properly supplied and had functional fixtures. Proper hand washing signs were observed inside the bathrooms. Starting at 9:48am., the water temperature was measured in both bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit.

COMMON AREAS: The LPA observed the living room and dining room area to be furnished appropriately and all furniture was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. The LPA observed required postings throughout the common space. Activities were observed in the living room. There is a working telephone on premises. Facility has an adequate amount of emergency food and water. No obstructions or hazards were observed inside or out.

GARAGE / BACKYARD: The LPA observed a refrigerator and freezer in the garage with additional food; in good condition. Washer and dryer on premises; residents do their own laundry needs; however, facility will assist if needed. Detergents and cleaning solutions were observed in a locked cabinet at the time of the visit. There is a shaded area in the backyard with appropriate furniture for resident use. The exterior passageways were clean and clear of any obstructions at the time of the visit. The LPA observed one (1) self-latching gate for emergency use. No bodies of water noted at the time of the visit.

RECORD REVIEW: The LPA reviewed five (5) Resident Records and three (3) Personnel Records including the current Administrator’s file starting at 10:10am.

Resident 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/IPP. All files were complete.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 12/19/2024

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

Report Continued from LIC 809C...

Personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, and first aid/CPR training. All records were in order.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2-i home.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Fire extinguisher was observed to be fully charged with a date of 07/31/2024. Emergency disaster drills are conducted quarterly, with the last one conducted on 11/07/2024.

During today’s visit, the LPA conducted an interview with one (1) staff. No concerns were noted.

MEDICATION REVIEW: The LPA conducted a medication review at approximately 12:00pm. Medications are locked in a file cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit.

No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3