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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850137
Report Date: 04/08/2022
Date Signed: 04/08/2022 04:12:54 PM

Document Has Been Signed on 04/08/2022 04:12 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,
, CA
FACILITY NAME:BERNADETTE HOME CARE IVFACILITY NUMBER:
565850137
ADMINISTRATOR:VILLAPANDO, JANETTEFACILITY TYPE:
740
ADDRESS:2131 DUNNIGAN STREETTELEPHONE:
(805) 444-4910
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 6DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Janette VillapandoTIME COMPLETED:
01:52 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:46PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Janette Villapando at 1:05PM and discussed the reason for the visit.

At 1:07PM, the LPA, along with facility 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. The following was observed:

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. At 01:13PM, the outdoor gate was observed to have a padlock. The padlock was removed during the visit. The garage was observed locked and contained the laundry area, as well as emergency food supply, PPE supply, and storage.

Two (2) fire extinguishers were observed to be fully charged and purchased on 01/14/2021.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are private resident rooms and 1 (one) is a shared resident room.

Report Continued on LIC 809-C

SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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: BERNADETTE HOME CARE IV
FACILITY NUMBER: 565850137
VISIT DATE: 04/08/2022
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RESTROOMS: The LPA observed 2 restrooms in the facility; one is a shared resident restroom and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff and visitors to be wearing masks. The LPA observed an adequate supply of Personal Protective 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’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
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