565850137-2-7-2023-29-AS-KDUK-CNTUXJ-20230207145825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850137
Report Date: 02/07/2023
Date Signed: 02/07/2023 02:58:33 PM

Document Has Been Signed on 02/07/2023 02:58 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:	BERNADETTE HOME CARE IV		FACILITY NUMBER:	565850137
ADMINISTRATOR:	VILLAPANDO, JANETTE		FACILITY TYPE:	740
ADDRESS:	2131 DUNNIGAN STREET		TELEPHONE:	(805) 444-4910
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6		CENSUS: 6	DATE:	02/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:24 PM
MET WITH:	Janette Villapando & Bernadette Abiera		TIME COMPLETED:	03:05 PM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 02:24PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Licensees Janette Villapando and Bernadette Abiera and discussed the reason for the visit. Entrance interview conducted.

At 02:25PM, the LPA, along with Licensees, 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:

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.

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. Water temperature was taken at 02:31PM in the common hallway restroom and measured at 120.0 degrees Fahrenheit, which is within the required range.

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. A fireplace was observed to be adequately screened at the time of the visit.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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: BERNADETTE HOME CARE IV	FACILITY NUMBER: 565850137
	VISIT DATE: 02/07/2023

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Two (2) fire extinguishers were observed to be fully charged and last serviced on 05/16/2022. Hardwired combination smoke and carbon monoxide detectors as well as fire door were tested at 02:38PM and were functional at the time of the visit.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. A locked shed was observed in the backyard and contained storage. The garage was observed locked and contained the laundry area, as well as emergency food supply, PPE supply and storage.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensees 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.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

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