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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609739
Report Date: 12/13/2021
Date Signed: 12/13/2021 04:03:42 PM

Document Has Been Signed on 12/13/2021 04:03 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:BIC BRAIN INJURY HOME AT BANNER AVENUEFACILITY NUMBER:
567609739
ADMINISTRATOR:VERONICA L ZEPEDAFACILITY TYPE:
735
ADDRESS:50 BANNER AVETELEPHONE:
(805) 561-9506
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY: 6CENSUS: 5DATE:
12/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:26 AM
MET WITH:Veronica ZepedaTIME COMPLETED:
11:34 AM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Case Management - Deficiencies visit at the facility. LPA met with Administrator Veronica Zepeda and Licensee/Representative Charles Watson.

During facility tour at 11:26 am with the Administrator and Licensee/Representative LPA observed Rust-Oleum primer, weed and grass killer, wood glue, stone sealer, isopropyl rubbing alcohol and cans of paint in an unlocked shed on the side of the house accessible to clients. Administrator stated that the shed is normally locked.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit interview was conducted, today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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 12/13/2021 04:03 PM - It Cannot Be Edited


Created By: Joann Rosales On 12/13/2021 at 12:08 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: BIC BRAIN INJURY HOME AT BANNER AVENUE
FACILITY NUMBER: 567609739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2021
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Administrator locked the storage shed during facility visit. Administrator stated that they will provide documentation of staff training regarding regulation 80087(g) to CCL by 12/23/21.
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Based on LPA’s observations, the licensee did not comply with the section cited above as toxic items were accessible to clients which poses an immediate health risk to persons 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021


LIC809 (FAS) - (06/04)
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