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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609976
Report Date: 03/11/2022
Date Signed: 03/11/2022 05:09:03 PM


Document Has Been Signed on 03/11/2022 05:09 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:BLUE BIRD CARE HOMEFACILITY NUMBER:
567609976
ADMINISTRATOR:ASPERIN, PRINCESS MFACILITY TYPE:
740
ADDRESS:1484 BLUE BIRD AVETELEPHONE:
(805) 765-6085
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 5DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Arlene MartinezTIME COMPLETED:
04:01 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Required 1 - Year visit to this facility. LPA met Arlene Martinez who is authorized to review and sign reports.

LPA conducted a facility tour to inspect for infection control practices. Infection control practices were discussed with staff Martinez. An inspection of the common areas, resident rooms and restrooms were conducted. LPA observed a sufficient supply of perishable and nonperishable food. PPE supplies were observed. LPA observed the fire extinguisher fully charged. The smoke detectors and carbon monoxide detectors were tested and operable. First Aid kit is complete. LPA observed appropriate lighting in residents rooms. Medications are stored in a locked medication cart. Outdoor area toured- passageways are free of obstruction. LPA reviewed resident records.

During facility tour at 2:51 pm with staff Martinez LPA observed disinfecting wipes on kitchen counter accessible to residents.

During facility tour at 3:02 pm with staff Martinez LPA observed hot water temperature at 135.9 degrees F. in resident bathroom.

During a review of the First Aid Kit at 3:10 pm with staff Martinez LPA observed aspirin tablets, alcohol wipes, insect sting relief towelettes, antacid tablets and non-aspirin tablets in an unlocked cabinet accessible to residents.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, todays reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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


Document Has Been Signed on 03/11/2022 05:09 PM - It Cannot Be Edited

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: BLUE BIRD CARE HOME
FACILITY NUMBER: 567609976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above as the water temperature read at 135.9 degrees F. in resident bathroom which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Staff turned down water heater temperature during facility visit.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above as disinfecting wipes, alcohol wipes and insect sting relief towelettes were accessible to residents which poses an immediate health risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Staff placed items in an inaccessible location during facility visit. Staff stated that they will provide documentaton of staff training regarding regulation 87309(a) to CCL by 3/21/22.

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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/11/2022 05:09 PM - It Cannot Be Edited

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: BLUE BIRD CARE HOME
FACILITY NUMBER: 567609976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above as aspirin tablets, antacid tablets and non-aspirin tablets were in an unlocked cabinet accessible to residents which poses an immediate health risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Staff placed First Aid Kit in a locked cabinet during facility visit. Staff stated that they will provide documentaton of staff training regarding regulation 87465(h)(2) to CCL by 3/21/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3