567609834-9-21-2023-29-AS-MARO-CVVQXX-20230921123417

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609834
Report Date: 09/21/2023
Date Signed: 09/21/2023 12:34:26 PM

Document Has Been Signed on 09/21/2023 12:34 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:	BCBN LLC E		FACILITY NUMBER:	567609834
ADMINISTRATOR:	FARRUGGIA, FABIANA		FACILITY TYPE:	735
ADDRESS:	2244 GLORYETTE AVE		TELEPHONE:	(805) 285-0294
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 4		CENSUS: 3	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Florencia Farruggia		TIME COMPLETED:	12:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a one year required annual at 8:00 a.m. The last annual conducted at this facility was on 09/15/2022. Upon arrival, the LPA was greeted at the door by Administrator, Florencia Farruggia and at this time the reason for the visit was explained. Entrance interview conducted.

At 8:06 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The kitchen/food area was observed at 8:16 a.m. The hot water temperature was measured at 116.6 degrees Fahrenheit at 8:17 a.m.. The facility has a sufficient supply of non-perishable and perishable food items. The LPA observed the knives and sharps stored in a locked drawer. Cleaning supplies and disinfectants are stored under the kitchen sink inaccessible to clients.

Common areas: Living room and dining room furniture was observed to be in good condition, and the lighting was adequate. The facility maintained a comfortable temperature. At 8:25 a.m., the smoke detector(s) and carbon monoxide detector were tested and were operational. The fire extinguisher was observed to be new and fully charged. There is a functioning telephone on the premises.

Backyard/Outdoor: The washer and dryer are in the backyard. Clients are responsible for their own laundry needs; however, staff will assist if needed. Facility files are stored in the office. The backyard has a covered outdoor area equipped with furniture for client use. The LPA observed one side gate that is self-closing and latched. Passageways were observed clear of obstructions in case of an emergency. There is an empty pool that was observed to be locked and inaccessible to clients at the time of the visit.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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: BCBN LLC E	FACILITY NUMBER: 567609834
	VISIT DATE: 09/21/2023

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(Report Continued from LIC 809...)

Restrooms: The two client restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature was measured and in compliance between 105- and 120-degrees Fahrenheit at the time of the visit.

Bedrooms: There are three (3) client rooms, which were furnished with appropriate linens and required furniture. Adequate lighting in all bedrooms was observed.

Records: The LPA reviewed client records at 8:45 a.m. and staff records at 9:10 a.m. The LPA reviewed three (3) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All client files were in order.

The LPA reviewed three (3) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All files were complete.

The LPA also audited the current Administrator’s file, and it was in order.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2-i home. The last disaster drill was conducted on 08/26/2023.

At the time of the visit, the LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster, and a copy of the liability insurance.

Medications: Medications review began at 10:00 a.m.; medications are centrally stored and locked in a cabinet by the kitchen. Medications are labeled and checked for expiration dates. No errors observed during the medication review.

No deficiencies were noted at this time. Exit interview conducted. Report was reviewed and a copy was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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