565850137-4-5-2024-29-AS-TCAA-D42L68-20240405082817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850137
Report Date: 04/04/2024
Date Signed: 04/05/2024 08:29:17 AM

Document Has Been Signed on 04/05/2024 08:29 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BERNADETTE HOME CARE IV		FACILITY NUMBER:	565850137
ADMINISTRATOR:	VILLAPANDO, GERARDO		FACILITY TYPE:	740
ADDRESS:	2131 DUNNIGAN STREET		TELEPHONE:	(805) 444-4910
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 6	DATE:	04/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Janette Villapando		TIME COMPLETED:	01:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 11:00 a.m. LPA met with Licensee/Administrator Janette Villapando and explained the reason for the visit.

At 11:10 a.m. LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguishers are fully charged and last serviced 5/15/2023. The smoke detectors and carbon monoxide detectors are combined units; they were tested and functioned properly. The facility has a fire door in the hallway which also functioned properly. No fire clearance concerns were 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 perishable and non-perishable food and water. Cleaning supplies are located in separate locked cabinets with additional supplies in the locked garage.

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. Exit doors contain alarms and were functional at the time of the visit.

BATHROOMS: There are two (2) bathrooms for resident use. One is located in a shared bathroom and one is a shared bathroom located in the hallway. Bathrooms were observed to be equipped with nonskid surfaces and grab bars. The water temperature measured 105*F which was within the required range.

BEDROOMS: There are four (4) private bedrooms and one shared bedroom. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

(continued on LIC809C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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: BERNADETTE HOME CARE IV	FACILITY NUMBER: 565850137
	VISIT DATE: 04/04/2024

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(continued from LIC809)

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture and the front porch is covered and equipped with furniture as well. All passageways were observed to be clear. There were no bodies of water on the premises.

RECORD REVIEW: Staff and resident records were reviewed. The files all appeared complete.

INTERVIEWS: Two (2) staff were interviewed; no concerns noted and staff answered questions appropriately. During today's visit, LPA attempted to interview residents, however due to medical conditions, interviews were not possible.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly.

MEDICATION REVIEW: Medications for two (2) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

No deficiencies cited. Exit interview conducted. A copy of today's report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC809 (FAS) - (06/04)

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