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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850482
Report Date: 04/02/2025
Date Signed: 04/03/2025 08:39:06 AM

Document Has Been Signed on 04/03/2025 08:39 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 VIFACILITY NUMBER:
565850482
ADMINISTRATOR/
DIRECTOR:		MICHELLE RIL RACANFACILITY TYPE:
740
ADDRESS:1525 DAPPLE AVETELEPHONE:
(805) 444-4910
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 5DATE:
04/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Michelle RacanTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. LPA arrived at 09:45 A.M. and met with caregiver, Leonilo Dela Cruz. Caregiver contacted the Administrators by phone. At 10:10 A.M. Administrator, Michelle Racan arrived at the facility with Licensee Representative Janette Villapando. Entrance interview conducted.

At 10:17 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 2/15/2025. The smoke detectors and carbon monoxide detectors are combined units; at 10:40 A.M 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. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted:

Bedrooms: There are 6 (six) 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.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 VI
FACILITY NUMBER: 565850482
VISIT DATE: 04/02/2025
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Continued from LIC 809

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 slip resistant mats and grab bars. Between 10:32 A.M. and 10:45 A.M. hot water was measured in all 3 (three) bathrooms and measured within the required range.

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. LPA observed all required postings on the wall in the main hallway/entryway. Additionally, LPA observed a complete first aid kit, PPE supplies such as gloves and mask and extra linens inside hallway cabinets. The facility maintained a comfortable temperature of 73 degrees. All facility exit doors contain functional audible alarms.

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. Knives and sharp objects are stored locked under the sink in a locked cabinet. At 10:53 A.M. hot water measured 111.8 degrees Fahrenheit. Resident files and staff files were observed to be stored inside locked kitchen cabinets. The facility has a sufficient supply of perishable and non-perishable food and water. LPA conducted a review of expiration dates on product labels.

Laundry Room: There is a locked laundry room; chemicals and cleaning supplies were observed in a locked cabinet inside the laundry room above the washer and dryer.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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 VI
FACILITY NUMBER: 565850482
VISIT DATE: 04/02/2025
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Continued from LIC 809-C

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. Facility has two total side gates; both were observed to be self-closing and self-latching with clear passageways for emergency exit use. Facility provides sufficient space to accommodate both indoor and outdoor activities.

Garage: The facility garage is attached to the home; however, it has a separate locked entry, and it remains locked and inaccessible to the residents in care. Garage was observed to contain emergency water and food supply, an extra fridge, as well as ample storage areas.

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, with the last drill documented on 01/24/2025.



RECORD REVIEW: Between 11:23 A.M. and 12:57 P.M. LPA conducted a file review of resident and staff records. All resident files were complete. During audit of staff files, LPA observed three (3) out of five (5) records reviewed to have incomplete Personnel Record (LIC501) form on file. Administrator was able to produce missing forms during today’s visit. Technical Violation issued (TV).

MEDICATION REVIEW: Medications are securely stored in a locked cabinet located in the kitchen. At 2:20 P.M. LPA reviewed medications for five (5) residents. All medications observed were labeled, stored, and properly documented at the time of the visit.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.

No deficiencies cited. Exit interview conducted. A copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4