567609661-3-20-2024-29-AS-KDUK-D3JSTB-20240320140916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609661
Report Date: 03/20/2024
Date Signed: 03/20/2024 02:09:20 PM

Document Has Been Signed on 03/20/2024 02:09 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 1		FACILITY NUMBER:	567609661
ADMINISTRATOR:	ABIERA, BERNADETTE		FACILITY TYPE:	740
ADDRESS:	510 MARISSA LN		TELEPHONE:	(818) 601-9089
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 6	DATE:	03/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:18 PM
MET WITH:	Bernadette Abiera		TIME COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:18PM. LPA met with Licensee/Administrator Bernadette Abiera. Entrance interview conducted.

Beginning at 12:24PM, the LPA, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. Please note: the facility is a 2-story house; the upstairs area is inaccessible to residents in care and is used for staff only, therefore was not observed. The following was observed in the downstairs area:

Fire extinguishers are fully charged and recently serviced 01/15/2024. Carbon Monoxide detector was tested at 01:32PM, smoke detectors were tested at 01:31PM and all were functional at the time of the visit. 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 seven (7) days non-perishable and two (2) days perishable food. Cleaning supplies and sharps are located in separate locked cabinets.

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. Both are designated for shared resident use. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in one shared resident bathroom and measured within the required range.

BEDROOMS: There are four (4) bedrooms in downstairs portion of the facility; two (2) are designated as

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 1	FACILITY NUMBER: 567609661
	VISIT DATE: 03/20/2024

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shared rooms and two (2) are designated as private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. The facility does contain an open carport, which is inaccessible to residents in care.

RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident files observed were in compliance with regulation. 5 (five) staff files observed contained all documents.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's 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 conducted on 03/02/2024.

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

INTERVIEWS: During today's visit, LPA interviewed 2 (two) staff and 2 (two) residents.

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