195850287-1-27-2023-29-AS-AASO-CNGUZX-20230127150216

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850287
Report Date: 01/27/2023
Date Signed: 01/27/2023 03:05:51 PM

Document Has Been Signed on 01/27/2023 03:05 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:	VALERIO RCFE		FACILITY NUMBER:	195850287
ADMINISTRATOR:	DONOVAN, REDSAND		FACILITY TYPE:	740
ADDRESS:	14315 VALERIO ST.		TELEPHONE:	(747) 264-0505
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 6	DATE:	01/27/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Frances Martir		TIME COMPLETED:	12:25 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) Angel Ascencio conducted a pre-licensing visit to the above noted facility. The LPA met with Administrator Frances Martir at 10:30 a.m. This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested and approved. The facility is a one story home. At 10:35 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for four (4) ambulatory residents, one (1) non-ambulatory residents; and/or, one (1) bedridden residents. The facility has six (6) private resident bedrooms. All resident rooms have direct exits to the outside. Room # 1 is approved as a non-ambulatory/ bedridden room. The facility does not have fire sprinkler. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are three (3) staff rooms within the facility. All rooms were free of odors. All window screens were clean and maintained in good repair. There are four (4) total bathrooms. Two (2) are designated as a resident bathroom and two (2) are staff restrooms. The resident bathroom(s) have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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: VALERIO RCFE	FACILITY NUMBER: 195850287
	VISIT DATE: 01/27/2023

NARRATIVE

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Resident and staff records are stored in filing cabinet which is currently located in the dinning area.
Medications are centrally stored in a locked cabinet by the kitchen. The first aid supplies were
complete, including a thermometer and a current version of a first aid manual. They were stored in a locked cabinet by the kitchen. Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils,
pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F)
and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is
adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation
area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans
had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet
located in the laundry area. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are
televisions and other entertainment equipment, games and/or activity supplies in the living room and
dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night
lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were
secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter
and exit the facility safely. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees
Fahrenheit. The facility does not have central air conditioning but are able to cool rooms to a
comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors
were tested and functioned properly during the time of visit. There are 2 fire extinguishers
throughout the property. They are fully charged and do not exceed the expiration date. Hot water was
tested in each bathroom, which included the resident bathroom(s) and any common bathrooms. The
laundry area is located next to the kitchen. The supply of extra bed and bath linens is adequate.
Personal hygiene items (shampoos, soaps) were adequate and are stored in a staff room.

Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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: VALERIO RCFE	FACILITY NUMBER: 195850287
	VISIT DATE: 01/27/2023

NARRATIVE

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Extra incontinence supplies are stored in garage and staff room. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the common hallways and resident rooms. The emergency telephone numbers are posted in the common hallway. Other required postings are posted in the dinning area.

The exterior passage ways were clean and clear of any obstructions. There is a covered
patio area at the front and back of the house with tables and chairs where residents can sit. The entire
property is fenced. There is an accessory dwelling unit (ADU) within the property that is not licensed that will be considered an additional staff room once inspection is cleared. There are no bodies of
water on the premises at the present time. The garage is not accessible from the house.

Pre-Licensing is complete and this facility has no deficiencies.

This report will be sent to the Centralized Application Bureau (CAB) once all
corrections are received. You will be notified by the CAB Analyst when your
license has been approved. You are not allowed to begin operating until you have
been notified that your license has been approved by the CAB Analyst. Failure to
comply could affect approval of your license.

Exit interview conducted and copy of the report was administered
.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC809 (FAS) - (06/04)

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