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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850297
Report Date: 10/10/2025
Date Signed: 10/10/2025 05:23:31 PM

Document Has Been Signed on 10/10/2025 05:23 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: 4CENSUS: 3DATE:
10/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Allan RacanTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 09:20 AM. LPA met with facility staff who contacted the facility Co-administrator Michelle Racan and the reason for the visit was explained. Licensee Representatives Bernadette Abiera and Janette Villapando were present for the visit, however they left before the visit ended. Administrator Allan Racan arrived at the facility at approximately 10:30 a.m. Entrance interview conducted and reason for the visit was explained to staff and Administrators.

The LPA, along with co-administrator Bernadette Abiera 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:

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 secure cabinet located under the kitchen sink to contain cleaning supplies and knives. LPA observed an additional fire extinguisher mounted in the kitchen to be fully charged and serviced on 08/15/2025.

COMMON AREAS: This includes the living room, hallway, and dining room. LPA observed all common areas 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. . Continued on LIC 809C, 2nd page.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2025
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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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: 10/10/2025
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The living room contained adequate seating and activities for resident use. LPA observed the living room to contain an appropriately screened fireplace. The facility’s fire and carbon monoxide alarms were tested and were functional at the time of the visit.

BEDROOMS: There are four (4) resident single occupancy bedrooms in the facility; of which one is vacant.. 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. At 10:17 a.m. the LPA observed bedroom number one being used as a passage way to a storage/closet inside. At approximately 3:00 p.m. the LPA observed bedroom number one being used as a passage way to a storage/closet inside again.

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 107.2 and 109 degrees Fahrenheit, water temperature was adjusted during the visit..

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. No bodies of water were observed.

RECORD REVIEW: Record review began at 10:52 AM. The LPA reviewed documentation of Infection Control, Emergency Disaster Plan and the facility’s last emergency disaster drill was conducted on 07/09/2025. Three (3) resident and Five (5) staff files 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. All records were complete and current.
Report will continue on LIC809-C, 3rd page.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
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 V
FACILITY NUMBER: 565850297
VISIT DATE: 10/10/2025
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MEDICATION REVIEW: LPA conducted a medication review for two (2) of three (3) residents and the following was observed: All medications were stored properly inaccessible to residents in care. During Resident #1 (R#1's) audit, the LPA observed zinc oxide paste skin protectant, silicone cream, menthol-zinc oxide .44-20 ointment without a prescription. Per Administrator Allan they are used on R1. LPA observed two unopened prescribed antifungal 2% miconazole nitrate cream tubes (with 9/29/25 filled date) and not documented on the Centrally Stored Medication and Destruction Record (CSMDR), and two unopen Calprotect 0.44-20.6% tubes with filled dates of 7/07/25 and 09/07/25. LPA observed the menthol-zinc oxide .44-20 ointment not documented on the CSMDR. The LPA observed Amlodipine besylate 10mg with a start date of 10/8, per MAR given at 8am, only 2 missing, based on count and start date, medication was not given as prescribed. During Resident #2 (R#2's) audit, the LPA observed Lamotrigine 25mg with a start date of 10/9/25 and only only 1 missing for morning bubble pack based on count and start date medication was not administered as prescribed. The LPA did not observed start dates for R2's potassium chloride and zonisamide

INTERVIEWS: LPA attempted to interview two (2) residents, however they were unable or unwilling to be interviewed.

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

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2025 05:23 PM - It Cannot Be Edited


Created By: Esther Cortez On 10/10/2025 at 04:59 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: 10/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two residents that were not given their medications as prescribed, and in one resident that was being administer medications without prescription which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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Administrator agrees to have a medication training with hospice and clarify which medications shall be administered to R1 and which are discontinued. Will submit proof to LPA by 10/17/25
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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2025 05:23 PM - It Cannot Be Edited


Created By: Esther Cortez On 10/10/2025 at 04:59 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: 10/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87308(c)
Resident and Support Services
(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage.

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 a closet in room 1 is used as a general storage closet and LPA observed room 1 being used as a passageway to the storage closet for items that belong to another resident and/or facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2025
Plan of Correction
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Administrator agrees to submit a self certification letter that the closet will not be used for general storage and will remove all items that do not belong to the resident in room 1.
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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
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