567609712-4-7-2025-29-AS-VCOY-DFHL4B-20250407082514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609712
Report Date: 03/13/2025
Date Signed: 04/07/2025 08:26:06 AM

Document Has Been Signed on 04/07/2025 08:26 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 II		FACILITY NUMBER:	567609712
ADMINISTRATOR/ DIRECTOR:	ABIERA, BERNADETTE		FACILITY TYPE:	740
ADDRESS:	1982 LATHAN AVE		TELEPHONE:	(805) 437-6302
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Bernadette Abiera		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:45 a.m. The LPA was greeted by Caregiver, Virginia Ching. Caregiver contacted the Administrators by phone, Bernadette Abiera and Jannette Villapando. At 10:00 a.m. Administrators arrived at the facility. LPA informed the reason for the visit. Entrance Interview.

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 7/15/2024. At 10:41 a.m the smoke detectors and carbon monoxide detectors are combined units; 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.

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. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly. The facility maintained a comfortable temperature of 73 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed.

BEDROOMS: There are 6 (six) total bedrooms; 5 (five) are designated as resident rooms - 1 (one) shared and 4 (four) private and 1 (one) is designated as a staff room. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Continued on LIC 809-C

Desaree Perera	TELEPHONE: (818) 596-4347
Valeria Conway	TELEPHONE: (818) 454-0485
	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

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 04/07/2025 08:26 AM - It Cannot Be Edited

Created By: Valeria Conway On 03/13/2025 at 03:03 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BERNADETTE HOME CARE II	FACILITY NUMBER: 567609712
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(c)(1)(A)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not having record of resident 1's Negative TB test result which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2025
	Plan of Correction
1 2 3 4	Administrators agreed to provide TB test result and new LIC 602 for Resident #1 before POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Perera

TELEPHONE: (818) 596-4347

LICENSING EVALUATOR NAME:

Valeria Conway

TELEPHONE: (818) 454-0485

LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

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 II	FACILITY NUMBER: 567609712
	VISIT DATE: 03/13/2025

NARRATIVE

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Continued from LIC 809-C

BATHROOMS: The LPA observed 3 (three) restrooms in the facility; one is a shared resident restroom, one is a private restroom, and one is a staff restroom. Restrooms were observed to be equipped with non-slip resistant surfaces and grab bars. Between 10:22 a.m. and 10:40 a.m. hot water temperature was measured in both bathrooms and was within the required range of 105 and 120 degrees Fahrenheit.

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food and water. LPA conducted a review of expiration dates on product labels. Cleaning supplies are located in a locked cabinet under the kitchen sink and separate from food supplies. At 10:43 a.m. hot water temperature measured at 110.7 degrees Fahrenheit.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture and the front porch is covered and equipped with furniture as well. All passageways were observed to be clear. There were no bodies of water on the premises. Facility has two total side gates; both were observed to be self-closing and self-latching gate with clear passageways for emergency exit use.

Garage/Laundry room: The garage is attached to the house, and it remains locked and inaccessible to the residents in care. Inside, LPA observed emergency food and emergency water, mobility aids such as walkers, wheelchairs, adult briefs. Additionally, in the garage is where the washer and dryer are kept. LPA observed detergents and chemicals securely locked inside a cabinet.

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.

Continued on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

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 II	FACILITY NUMBER: 567609712
	VISIT DATE: 03/13/2025

NARRATIVE

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Continued on LIC 809-C

RECORD REVIEW: Between 11:08 a.m. and 12:39 p.m. LPA conducted a file review of resident and staff records. During the resident files review, LPA observed that Resident #1’s (R1’s) physician’s report (LIC 602A) indicated their ambulatory status as bedridden. However, during the facility walkthrough, LPA observed R1 seated in a wheelchair in the living room watching TV. Per facility administrators, an amended LIC 602 will be submitted by R1’s case manager to reflect R1’s current ambulatory status and a copy will be sent to LPA. Furthermore, LPA observed a refusal TB test for R1. Reason for refusal was that a chest Xray was taken on 12/31/2024. However, LPA noted that the medical documentation providing this information was dated on 12/31/2025. All staff files reviewed were complete during today’s visit.

MEDICATION REVIEW: Medications are securely stored in a locked closet located in the main hallway. At 1:45 p.m. LPA reviewed medications for six (6) residents. All medications observed were labeled, stored, and properly documented at the time of the visit.

INTERVIEWS: Two (2) staff were interviewed; no concerns noted, and staff answered questions appropriately. During today's visit, LPA was not able to interview residents due to medical conditions.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC809 (FAS) - (06/04)

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