567609661-1-16-2025-29-AS-VCOY-DCYMHC-20250116083715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609661
Report Date: 01/15/2025
Date Signed: 01/16/2025 08:37:34 AM

Document Has Been Signed on 01/16/2025 08:37 AM - 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 1		FACILITY NUMBER:	567609661
ADMINISTRATOR/ DIRECTOR:	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:	01/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Bernadette Abiera		TIME VISIT/ INSPECTION COMPLETED:	03:00 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) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:15 A.M. LPA met with administrator Bernadette Abiera. At 10:30 A.M. Janette Villapando, co-administrator joined the visit. Entrance interview conducted.

Beginning at 10:40 A.M. the LPA, along with administrator and co-administrator 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. Please note: the facility is a 2-story house; the upstairs area is inaccessible to residents in care and is used for staff only, therefore was not observed. The following was observed in the downstairs area:

Fire extinguishers are fully charged and recently serviced 04/15/2024. Carbon Monoxide detector was tested at 11:02 A.M. smoke detectors were tested at 11:04 A.M and all were functional at the time of the visit. No fire clearance concerns were observed.

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. LPA conducted a review of expiration dates on product labels. Cleaning supplies and sharps are located in separate locked cabinets. At 11:40 A.M. hot water measured 117.7 degrees Fahrenheit.

COMMON AREAS: This includes the living room and dining room areas. LPA observed common areas to be clean and properly furnished at the time of the visit. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 71 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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 1	FACILITY NUMBER: 567609661
	VISIT DATE: 01/15/2025

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
26
27
28
29
30
31
32

Continued from LIC 809

BATHROOMS: There are two (2) bathrooms for resident use. Both are designated for shared resident use. Restrooms were observed to be equipped with slip resistant surfaces and contain slip resistant mats. Grab bars were observed in the bathrooms. The water temperature was measured in one shared resident bathroom and measured within the required range.

BEDROOMS: There are four (4) bedrooms in downstairs portion of the facility; two (2) are designated as shared rooms and two (2) are designated as private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. The front yard is free of obstructions, the two side gates are self-latching. All passageways were observed to be clear. There were no bodies of water on the premises at the time of the visit. The facility does contain an open carport/garage, which is inaccessible to residents in care.

GARAGE: Garage is detached from the main house and inaccessible to the residents in care. Garage contained extra beds, extra mobility devices, PPE and incontinence supplies, and emergency food and water.

MEDICATION REVIEW: Medications review began at 11:30 A.M. Medications for six (6) residents were observed. Medications are centrally stored and locked in a cabinet in the living area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during today’s medication review.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 1	FACILITY NUMBER: 567609661
	VISIT DATE: 01/15/2025

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
26
27
28
29
30
31
32

Continued from LIC 809-C

RECORD REVIEW: At 12:13 P.M. 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, and personal rights. Six (6) resident files were reviewed. LPA observed that Resident #1 (R1) had outdated Physician’s report (LIC 602) and Needs and Service plan. Additionally, Resident #2 (R2) had an outdated Needs and Service plan. Administrator stated that due to fires in the area in early November 2024 these forms were not updated. Technical violation issued. Five (5) staff files were observed to contain all required documents.

Additionally, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. Emergency disaster drills are conducted quarterly, with the last drill conducted on 09/16/2024.

LPA requested the following documents, Personnel Roster LIC (500), Liability Insurance, and Resident Roster.

INTERVIEWS: During today's visit, LPA interviewed one (1) staff and one (1) resident.

No deficiencies cited. Exit interview conducted. A copy of today's report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3