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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850482
Report Date: 08/12/2024
Date Signed: 08/12/2024 04:16:33 PM


Document Has Been Signed on 08/12/2024 04:16 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 VIFACILITY NUMBER:
565850482
ADMINISTRATOR:VILLAPANDO, JANETTEFACILITY TYPE:
740
ADDRESS:1525 DAPPLE AVETELEPHONE:
(805) 444-4910
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 4DATE:
08/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Michelle RacamTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20240703104847). The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation.

During the complaint investigation of complaint # 29-AS-20240703104847, the following deficiency was observed: On 06/13/2024, Resident #1 (R1) had an unusual incident while at the facility where it states that around 8:50 a.m., caregiver on duty reported that R1 was agitated and banging their head on the wall while yelling and screaming. The caregiver reported that R1 sustained a bruise on their right forehead. On 07/09/2024, Incident report pertaining to R1 was provided to LPA; however, incident report was not reported to the Department prior to the visit as there was no documentation to show proof indicating that they submitted within the seven (7) days of occurrence as required by the California Code of Regulations.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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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Document Has Been Signed on 08/12/2024 04:16 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2024
Section Cited
CCR
87211(a)(1)(D)

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A written report shall be submitted to the licensing agency within seven days of the occurrence which threatens the welfare, safety or health of any resident…

This requirement was not met as evidenced by:
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The Administrator will review Regulation 87211 – Reporting Requirements and submit a statement of understanding to CCL on or before POC due date.
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Based on record review, the licensee did not comply with the section cited above as R1’s unusual incident report from 06/13/2024 was not submitted to the Department within the seven (7) days of occurrence, which posed a potential health and safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
LIC809 (FAS) - (06/04)
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