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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609661
Report Date: 08/31/2021
Date Signed: 08/31/2021 12:49:12 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2021 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20210823121422
FACILITY NAME:BERNADETTE HOME CARE 1FACILITY NUMBER:
567609661
ADMINISTRATOR:ABIERA, BERNADETTEFACILITY TYPE:
740
ADDRESS:510 MARISSA LNTELEPHONE:
(818) 601-9089
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 6DATE:
08/31/2021
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Bernadette AbieraTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Licensee is camouflaging medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced initial complaint inspection at the facility today. The LPA arrived at 10:11AM and met with Licensee/Administrator Bernadette Abiera. The LPA informed Licensee of the reason for today's inspection.

During today's visit, LPA Dulek conducted a facility tour with Licensee Abiera at 10:25 AM, staff interviews between 10:34AM and 11:00AM, interviewed residents between 11:11AM and 11:24AM and gathered copies of documents pertinent to the investigation. The following was then determined:

Interviews revealed that 2 (two) of the 6 (six) current residents have medication crushed and mixed with applesauce. LPA confirmed there are current Physician's Orders for medications to be administered in this manner. Residents interviewed stated staff give them their medications as prescribed and that staff communicate when they are to take their medications. Therefore, there is insufficient evidence to support the
REPORT CONTINUED ON LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20210823121422
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 1
FACILITY NUMBER: 567609661
VISIT DATE: 08/31/2021
NARRATIVE
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 and the allegation that "Licensee is camouflaging medication" is deemed UNSUBSTANTIATED at this time.

No citations were issued. A copy of this report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3