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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850137
Report Date: 04/15/2025
Date Signed: 04/15/2025 02:40:06 PM

Document Has Been Signed on 04/15/2025 02:40 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BERNADETTE HOME CARE IVFACILITY NUMBER:
565850137
ADMINISTRATOR/
DIRECTOR:		VILLAPANDO, GERARDOFACILITY TYPE:
740
ADDRESS:2131 DUNNIGAN STREETTELEPHONE:
(805) 444-4910
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 5DATE:
04/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Janette VillapandoTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:10 A.M. LPA met with Licensee/Administrator Janette Villapando and explained the reason for the visit.

At 10:25 A.M. LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguishers are fully charged and last serviced 07/19/2024. At 11:00 A.M. the smoke detectors and carbon monoxide detectors are combined units; they were tested and functioned properly. The facility has two (2) fire doors to enhance safety and prevent the spread of fire. One in the hallway and one in room #1. LPA observed hallway fire door functioning properly. This facility doesn’t have a staff room, facility will provide 24/7 care.


KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food and water. LPA conducted a review of expiration dates on product labels. The LPA observed that four (4) items were past their expiration date. Administrator discarded all four (4) items during today’s visit. Technical Violation Issued. LPA observed sharps and knives locked in a kitchen drawer. At 10:35 A.M. hot water measured at 115.6 * F. Cleaning supplies are located in separate locked cabinets with additional supplies in the locked garage.



Garage/Laundry room: Inside the locked garage, LPA observed the washer and dryer, emergency water and emergency food, cleaning supplies and disinfectants. The Garage remains locked and inaccessible to the residents in care.
Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/15/2025 02:40 PM - It Cannot Be Edited


Created By: Valeria Conway On 04/15/2025 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BERNADETTE HOME CARE IV
FACILITY NUMBER: 565850137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having an industrial doorstop holding firedoor in room # 1 open which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2025
Plan of Correction
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Administrator removed doorstop and stated that door will remain closed at all times. Licensee will provide a statement of understanding on fire clearance.
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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2025 02:40 PM - It Cannot Be Edited


Created By: Valeria Conway On 04/15/2025 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BERNADETTE HOME CARE IV
FACILITY NUMBER: 565850137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(b)
Storage Space and Access
(b) Residents may have access to items specified in subsection (a) for personal use unless there is documentation, as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record reviewed, the licensee did not comply with the section cited above by having an unlocked closet containing air freshener and bathroom items with a broken magnetic lock with two (2) residents at risk which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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During today's visit administrator fixed the magnetic lock.
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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BERNADETTE HOME CARE IV
FACILITY NUMBER: 565850137
VISIT DATE: 04/15/2025
NARRATIVE
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Continued from LIC-809-C

Garage/Laundry room: Inside the locked garage, LPA observed the washer and dryer, emergency water and emergency food, cleaning supplies and disinfectants. The Garage remains locked and inaccessible to the residents in care.

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 72 degrees. During the inspection, the LPA observed a hallway closet. On the upper shelves, the LPA noted an ample supply of linens. On the lower shelves, the LPA observed various bathroom items including but not limited to air freshener, Vaseline and shampoo. It was further observed that the magnetic lock intended to secure the closet was broken at the time of the visit. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. The LPA observed the required postings in the common area and fireplace was observed adequately screened.

BATHROOMS: There are two (2) bathrooms for resident use. One is located in a shared bedroom, and one is a shared bathroom located in the main hallway. Bathrooms were observed to be equipped with slip resistant surfaces and grab bars. Between 10:49 A.M. and 10:53 A.M. hot water temperature measured between 105* - 120 *F which was within the required range.

BEDROOMS: There are four (4) private bedrooms and one shared bedroom. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. During the inspection, the LPA observed that Room #1, an approved bedridden room equipped with a fire-rated door, had an industrial doorstop in place, propping the door open. The administrator explained that Resident #1 prefers door to remain open, however, administrator immediately removed the doorstop during today’s visit and acknowledged that the door will remain closed at all times in compliance with fire safety requirements.

Continued on LIC-809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BERNADETTE HOME CARE IV
FACILITY NUMBER: 565850137
VISIT DATE: 04/15/2025
NARRATIVE
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Continued from LIC 809-C

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture and the front porch is covered and equipped with furniture as well. Facility has one side gate; LPA observed the side gate to be self-closing and self-latching gate with clear passageways for emergency exit use. During the inspection the LAP observed a locked shed located in the backyard. Upon entry, LPA noted the presence parts of a bed frame, a couch and various clothing items hanging on hangers inside the shed. The LPA remined the facility administrator that, in accordance with fire safety regulations, no individual is permitted to sleep or reside in the shed. There were no bodies of water on the premises.

RECORD REVIEW: Between 11:38 A.M. and 1 P.M., staff and resident records were reviewed. LPA observed Resident #1 and Resident #2 to be at risk if allowed direct access to personal grooming and hygiene items. All records were observed to be complete.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill documented on 04/08/2025.

MEDICATION REVIEW: Between 1:10 P.M. and 2:30 P.M. Medications for five (5) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC809 (FAS) - (06/04)
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