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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850297
Report Date: 10/24/2024
Date Signed: 10/24/2024 03:06:11 PM

Document Has Been Signed on 10/24/2024 03:06 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 VFACILITY NUMBER:
565850297
ADMINISTRATOR/
DIRECTOR:		ALLAN RACANFACILITY TYPE:
740
ADDRESS:1155 ECHO STTELEPHONE:
(805) 824-2523
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 6CENSUS: 5DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:06 AM
MET WITH:Michelle RacanTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:06 AM. LPA met with facility staff who contacted the facility administrator Michelle Racan. The administrator arrived to the facility at 10:56 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 10:09 AM, the LPA, along with facility staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS: This includes the living room, hallway, and dining room. LPA observed the dining room to be clean and properly furnished at the time of the visit. The dining room contains a dining table with adequate seating for resident use. LPA observed the dining room to contain two (2) secured cabinets which contained resident medications and facility files. LPA observed the living room wall to contain all required postings. The living room was observed to be clean and in good repair. LPA observed a fire extinguisher mounted in the living room to be fully charged and serviced on 08/15/2024. The living room contained adequate seating and activities for resident use. LPA observed the living room to contain an appropriately screened fireplace. LPA observed a hallway closet to contain first aid supplies and extra care supplies. The facility’s fire and carbon monoxide alarms were tested at 10:50 AM and were functional at the time of the visit.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured cabinet to contain knives. LPA observed a secure cabinet located under the kitchen sink to contain cleaning supplies. LPA observed an additional fire extinguisher mounted in the kitchen to be fully charged and serviced on 08/15/2024. Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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Document Has Been Signed on 10/24/2024 03:06 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/24/2024 at 12:57 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 V
FACILITY NUMBER: 565850297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 as an unsecured pair of green handled scissors were left unsecured in bathroom number 1 making them accesable to clients in care which poses an immediate safety risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Facility staff secured the scissors at the time of the visit POC cleared.
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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


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 V
FACILITY NUMBER: 565850297
VISIT DATE: 10/24/2024
NARRATIVE
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GARAGE: LPA observed the garage to be locked and inaccessible to clients in care. The garage was observed to contain cleaning supplies, extra care supplies, adequate emergency food and water supplies, an extra refrigerator, and the facility’s washer and dryer.

OUTDOOR SPACE: The facility has two (2) emergency exit gates leading to the front yard of the facility. LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed a secured storage shed to contain extra wheelchairs and household supplies. All exits to the exterior of the facility contained auditory alarms and all were functional at the time of the visit.

BEDROOMS: There are four (4) bedrooms in the facility; two (2) are dual occupancy rooms and two (2) are single occupancy rooms. Bedroom number one (1) is designated as the facility’s bedridden approved room. LPA and facility staff toured all four (4) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Four (4) resident beds were observed to contain full bed rails.

BATHROOMS: There are three (3) bathrooms in the facility. Two (2) bathrooms are designated as private resident bathrooms, and one (1) bathroom is designated as a shared resident bathroom. All resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers all were properly secured. The water temperature was measured between 116.4 and 118.4 degrees Fahrenheit, which is in compliance with regulation. At 10:31 AM LPA observed bathroom one (1) to contain an unsecured pair of green handled scissors making them accessible to residents in care.

RECORD REVIEW: Record review began at 10:58 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed all resident files contained all required documentation and signatures. No deficiencies were observed during record review. Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 V
FACILITY NUMBER: 565850297
VISIT DATE: 10/24/2024
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MEDICATION REVIEW: Medication review began at 12:10 PM. Medications for three (3) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 09/25/2024. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator.

INTERVIEWS: LPA interviewed two (2) staff members. Both staff interviewed understood their roles and responsibilities, The resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. LPA attempted to interview the facility’s residents, but all residents were unable/unwilling to speak with the LPA.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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