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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609834
Report Date: 09/17/2024
Date Signed: 09/17/2024 12:26:29 PM

Document Has Been Signed on 09/17/2024 12:26 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 EFACILITY NUMBER:
567609834
ADMINISTRATOR/
DIRECTOR:		FARRUGGIA, FABIANAFACILITY TYPE:
735
ADDRESS:2244 GLORYETTE AVETELEPHONE:
(805) 285-0294
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 4CENSUS: 3DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Fabiana FarruggiaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today at 9:30am. Upon arrival, the facility was empty. LPA contacted Administrator via telephone and the reason for the visit was explained. The Administrator, Fabiana Farruggia arrived at 9:57am. The three (3) residents were at the day program at the time of the visit. Entrance interview conducted.

During today’s visit, the LPA along with the 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. The following was 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; properly stored. Refrigerator and dry food pantry were checked for proper labels and expiration dates. Knives and sharps were observed in a locked drawer inaccessible to residents in care. Cleaning supplies and toxins were observed locked and inaccessible under the kitchen sink.

BEDROOMS: There are three (3) bedrooms for resident use and one (1) bedroom designated for staff only. One (1) bedroom is designated as double occupancy; and two (2) bedrooms are designated as single occupancy. LPA observed all resident bedrooms to be properly furnished with a bed, nightstand, and sufficient lighting. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. LPA observed additional clean linens, towels, and personal hygiene items in the hallway closet.

Report Continued on LIC 809C…

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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 3
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: 09/17/2024
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Report Continued from LIC 809…

BATHROOMS: There are two (2) bathrooms for resident use. Bathrooms were observed to be equipped with nonskid surfaces and grab bars. LPA observed bathrooms to be clean, properly supplied and had functional fixtures. Proper hand washing signs were observed inside the bathrooms. Starting at 10:05am., the water temperature was measured in both bathrooms, and they measured between 113.1- and 119.1-degrees Fahrenheit.

COMMON AREAS: LPA observed the living room and dining room area to be furnished appropriately and all furniture was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space. Activities were observed in the living room. There is a working telephone on premises. Facility has an adequate amount of emergency food and water. No obstructions or hazards were observed inside or out.

OUTDOOR / BACKYARD: There is a shaded area in the backyard with appropriate furniture for resident use. Washer and dryer were observed in the backyard. Detergents and cleaning solutions were observed in a locked cabinet at the time of the visit. The exterior passageways were clean and clear of any obstructions at the time of the visit. LPA observed one (1) self-latching gate for emergency use. There is an empty pool that was observed to be locked and inaccessible to clients at the time of the visit. The garage is maintained locked and inaccessible to residents in care.



RECORD REVIEW: LPA reviewed three (3) Resident Records and two (2) Personnel Records including the current Administrator’s file starting at 10:24am.

Resident files were reviewed 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/IPP. All files were complete.

Report Continued on LIC 809C…

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 09/17/2024
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Report Continued from LIC 809C…

Personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, and first aid/CPR training. All records were in order.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2-i home.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, 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. Fire extinguisher was observed to be fully charged with a date of 04/17/2024. Emergency disaster drills are conducted quarterly, with the last one conducted on 08/17/2024.

During today’s visit, LPA obtained copies of Personnel Report (LIC 500), Resident Roster (LIC 9020), and Emergency Disaster Plan (LIC 610D).

MEDICATION REVIEW: LPA conducted a medication review at approximately 11:40am. Medications are locked in a cabinet by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit.

No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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