565850482-3-20-2024-29-AS-KDUK-D3JQBJ-20240320120138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850482
Report Date: 03/20/2024
Date Signed: 03/20/2024 12:03:26 PM

Document Has Been Signed on 03/20/2024 12:03 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:	BERNADETTE HOME CARE VI		FACILITY NUMBER:	565850482
ADMINISTRATOR:	VILLAPANDO, JANETTE		FACILITY TYPE:	740
ADDRESS:	1525 DAPPLE AVE		TELEPHONE:	(805) 444-4910
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 0	DATE:	03/20/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Janette Villapando, Bernadette Abiera, Michelle Racan		TIME COMPLETED:	12:05 PM

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Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing inspection for this proposed facility. LPA arrived at 09:43AM and met with Licensee Representatives Janette Villapando, Bernadette Abiera, and Michelle Racan. Entrance interview conducted.

Fire clearance was approved on 01/18/2024 for 6 (six) total residents, all of which may be non-ambulatory. The facility has an approved hospice waiver for 6 (six) and a pending dementia care plan. A tour of the facility was initiated at 09:54AM with the licensee representatives. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted:

Fire extinguishers were purchased on 12/01/2023. Hardwired combination smoke/carbon monoxide detectors, as well as fire door were tested during today’s visit at 10:03AM and were functional at the time of the visit. LPA observed all required postings on the wall in the main hallway/entryway.

Bedrooms: There are 5 (five) total bedrooms in the facility; 4 (four) are designated for private resident use and 1 (one) is a shared room. All resident bedrooms were inspected and contained appropriate furnishings and linens. The facility also contains a staff room, which was observed to be locked.

Bathrooms: The facility contains 3 (three) full bathrooms; 1 (one) is located in the hallway and is designated for shared use, 1 (one) is a private resident restroom, and 1 (one) is designated for staff and resident use. LPA observed all 3 (three) bathrooms were clean, properly supplied and had functional fixtures. LPA observed all bathrooms to have non-skid mats and grab bars. Hot water was measured in 2 (two) of the 3 (three) bathrooms and measured within the required range.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of non-perishable food at the facility; properly stored. Cleaning supplies are Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BERNADETTE HOME CARE VI	FACILITY NUMBER: 565850482
	VISIT DATE: 03/20/2024

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stored under the sink in a locked cabinet. Knives and sharp objects are stored locked.

Medication: Medications, resident files and staff files will be stored in separate locked kitchen cabinets. First aid supplies are available, and were observed to be complete.

Common Areas: These included the dining area and living room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a designated telephone available for resident use. There are nightlights in all common hallways/rooms providing ample lighting to common bathrooms. A fireplace, which was properly screened, was observed in the living room. There is a locked laundry room; chemicals were observed in a locked cabinet inside the locked laundry room.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. All passageways and exits were observed to be clear and free of hazards. All facility exit doors contain functional audible alarms.

Garage: The facility garage has a separate locked entry. Garage was observed to contain emergency water and food supply as well as ample storage areas.

In addition, during today’s visit, LPA conducted the Component III Orientation with the licensee representatives.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new license until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC809 (FAS) - (06/04)

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