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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850297
Report Date: 09/29/2022
Date Signed: 10/11/2022 02:22:32 PM

Document Has Been Signed on 10/11/2022 02:22 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:BERNADETTE HOME CARE VFACILITY NUMBER:
565850297
ADMINISTRATOR:RACAN, MICHELLEFACILITY TYPE:
740
ADDRESS:1155 ECHO STTELEPHONE:
(805) 824-2523
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 6CENSUS: DATE:
09/29/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:RACAN, MICHELLETIME COMPLETED:
02:22 PM
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COMP II by CAB successfully completed

Method: Phone Call at CAB

COMP II Participants: RACAN, MICHELLE

Capacity: 6

Census (if any clients in care):

Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program

2. Staff qualifications and responsibilities

3. Applicant and Administrator qualifications

4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions

5. Grievances, Complaints, Community resources

6. Physical plant, food service

7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property

SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Gina Baldwin
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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