567609661-2-7-2023-29-AS-KDUK-CNTT8V-20230207133058

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609661
Report Date: 02/07/2023
Date Signed: 02/07/2023 01:31:10 PM

Document Has Been Signed on 02/07/2023 01:31 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 1		FACILITY NUMBER:	567609661
ADMINISTRATOR:	ABIERA, BERNADETTE		FACILITY TYPE:	740
ADDRESS:	510 MARISSA LN		TELEPHONE:	(818) 601-9089
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6		CENSUS: 6	DATE:	02/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Bernadette Abiera		TIME COMPLETED:	01:38 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:35PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Licensee Bernadette Abiera and discussed the reason for the visit. Entrance interview conducted. The LPA, along with Licensee, toured the physical plant areas inside and outside at 12:45PM to ensure there are no health and safety hazards. The following was observed: KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. RESTROOMS: 2 restrooms were observed to be clean and sanitary and in operating condition. Showers were observed to have grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products in each restroom. Water temperature was measured in a common restroom at 12:47PM and measured at 113.9 degrees Fahrenheit, which is within the required range. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 4 total bedrooms downstairs – two (2) bedrooms are designated as shared resident rooms and two (2) are private rooms. Upstairs area contains staff living quarters and was observed to be inaccessible to residents in care. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/07/2023

NARRATIVE

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condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway.

Fire extinguishers were observed to be serviced on 07/11/2022. Hardwired combination smoke and carbon monoxide detectors were tested at 12:52PM and were functional at the time of the visit.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage was observed and contained locked storage cabinet for laundry supplies and emergency food supplies.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s
infection control practices. There is 1 entry into the facility. Upon entry, the facility has a central
point for symptom screening. LPA noted that the facility is allowing visitors for both indoor and outdoor
visitation. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

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