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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609661
Report Date: 08/31/2021
Date Signed: 08/31/2021 12:47:57 PM

Document Has Been Signed on 08/31/2021 12:47 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Bernadette AbieraTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management-Deficiencies visit to issue citations for deficiencies observed during the investigation of complaint control #29-AS-20210823121422, unrelated to the complaint allegations.

During the facility tour the LPA conducted along with Licensee/Administrator Bernadette Abiera at 10:25AM, LPA observed expired mustard and 3 cans of expired Vienna Sausage. In addition, LPA observed containers of food inside the refrigerator. Two (2) food containers had their lids placed on the top, but were not closed properly, fresh watermelon was on a plate and was uncovered, and LPA observed food containers not labeled with a date or contents. In the freezer, there were four (4) Ziploc bags of meat. Licensee stated the food was purchased yesterday and bagged for storage. However, the bags were not labeled with a date or contents.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, report issued, and appeal rights 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
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 08/31/2021 12:47 PM - It Cannot Be Edited


Created By: Kelly Dulek On 08/31/2021 at 12:16 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 1
FACILITY NUMBER: 567609661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2021
Section Cited
CCR
87555(b)(9)

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87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This requirement is not met as evidenced by:
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Administrator/Licensee agreed to conduct a full food audit in the facility kitchen to ensure all expired foods are disposed of and all food remaining in the facility is properly labeled, covered, and stored by POC due date. Photos of covered and labeled food will be provided to CCL by POC due date
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Based on observation, during facility tour, LPA observed meats in the freezer, which were bagged, but not labeled with contents or date, LPA also observed expired food, and leftover food in the refrigerator that was unlabeled and improperly stored, which poses a potential risk to the health and safety to residents in care.
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021


LIC809 (FAS) - (06/04)
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