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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561701197
Report Date: 01/21/2022
Date Signed: 01/21/2022 01:22:45 PM

Document Has Been Signed on 01/21/2022 01:22 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:IBARRA ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
561701197
ADMINISTRATOR:MARIA S. CASTILLOFACILITY TYPE:
735
ADDRESS:5228 KATHERINE STTELEPHONE:
(805) 842-1061
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 4CENSUS: 4DATE:
01/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maria Ibarra - Administrator TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual. This annual had a specific emphasis on infection control practices and procedures. Upon arrival LPA was met by Administrator Maria Ibarra.

LPA 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. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was fully charged and last serviced Aug 2021.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives and sharps are stored in a locked cabinet to the right of the oven.



Bedrooms: There were three bedrooms designated for clients' use. All bedrooms were properly furnished and had appropriate bedding and linens. There is a staff room that is kept locked when not in use. LPA observed staff room to be empty at this time.

Bathrooms: There were two bathrooms designated for clients' use. Both bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was measured at 110 degrees Fahrenheit.

Common Areas: These included the living rooms and dining areas. The common areas were properly furnished. Properly labeled medications were locked in a cabinet in the dining area. The laundry area was in the back room off the dining area, detergents and cleaning supplies are kept in a locked cabinet.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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: IBARRA ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 561701197
VISIT DATE: 01/21/2022
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Continued from 809

Surrounding Grounds: The pool is kept secured from residents. Emergency/disaster supplies are stored in a locked closet just inside the garage. There were 2 storage units kept outside. LPA observed both to store bicycles at this time.


INFECTION CONTROL: During today’s visit, LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

Exit interview conducted. Report issued and sent via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC809 (FAS) - (06/04)
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