565850297-10-12-2023-29-AS-TCAA-CWJLP5-20231012085521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850297
Report Date: 10/11/2023
Date Signed: 10/12/2023 08:55:58 AM

Document Has Been Signed on 10/12/2023 08:55 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 V		FACILITY NUMBER:	565850297
ADMINISTRATOR:	RACAN, MICHELLE		FACILITY TYPE:	740
ADDRESS:	1155 ECHO ST		TELEPHONE:	(805) 824-2523
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	6	CENSUS: 4	DATE:	10/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:21 PM
MET WITH:	Michelle Racan		TIME COMPLETED:	05:30 PM

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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Required - 1 Year inspection at the facility today. LPA met with co-administrators Michelle Racan and Janette Villapando. The licensee Bernadette Abiera joined a little later.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and garage. Cleaning supplies and items that could pose a danger were secured in locked cabinets. The facility has a supply of emergency food and water.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and condition. All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and dining room furniture was observed to be in good condition. The fire extinguisher was fully charged and last serviced on 8/30/2023. The carbon monoxide detector and smoke detectors in the home and bedrooms were tested and were operational. Medications are centrally stored and in a locked cabinet in the dinning room. Cleaning supplies were observed to be locked in the garage and inaccessible to residents in care. The backyard has covered seating for resident use.

BEDROOMS: There are four resident bedrooms; two shared rooms and two private rooms. Bedrooms were furnished with clean linens, appropriate furnishings and sufficient lighting.

Report continued on LIC 809-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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 V	FACILITY NUMBER: 565850297
	VISIT DATE: 10/11/2023

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RESTROOMS: The facility has one common restroom and two private restrooms for residents. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. The hot water temperature in the common hallway restroom measured at 117.6*F.

MEDICATIONS: Medications are locked and centrally stored in a locked cabinet in the dining room area. Medications were reviewed and appear to be given as prescribed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. The LPA inspected the first aid kit, which was complete.

RECORDS: LPA reviewed client files and staff records. Client files were complete. Staff records were complete. All staff scheduled at the facility have criminal background clearance and association to this facility. Training records, disaster drills and disaster plan were complete. The facility has a sufficient supply of personal protective equipment.

No deficiencies were cited during today's inspection. Exit interview and reported reviewed with the Administrator. A copy of the 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: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC809 (FAS) - (06/04)

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