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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850287
Report Date: 08/20/2024
Date Signed: 08/20/2024 03:03:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/16/2024 and conducted by Evaluator Angela Barutyan
COMPLAINT CONTROL NUMBER: 29-AS-20240816081953
FACILITY NAME:VALERIO RCFEFACILITY NUMBER:
195850287
ADMINISTRATOR:DONOVAN, KOHLFACILITY TYPE:
740
ADDRESS:14315 VALERIO STTELEPHONE:
(747) 264-0505
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 6DATE:
08/20/2024
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Michael CustodioTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not ensure the kitchen was free of pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above at 09:32AM. LPA met with staff and Administrator Designee (AD) Michael Custodio and explained the reason for the visit.

During today's visit, LPA conducted a physical plant tour at 09:35AM, conducted interviews with residents, staff, and AD around 10:15AM, and reviewed and obtained copies of pertinent documents.

At approximately 10:25AM, LPA discussed allegation with AD.

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
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-20240816081953
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VALERIO RCFE
FACILITY NUMBER: 195850287
VISIT DATE: 08/20/2024
NARRATIVE
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It was alleged that staff do not ensure the kitchen was free of pests. Additional information received by a credible witness reported that the facility has been attempting to treat the infestation on their own for months with no success. During the plant tour, between 09:40AM-10:00AM, the LPA observed dead and alive roaches and flies in the kitchen pantry and refrigerator. During the visit, staff informed LPA that the infestation has been happening for a few months. The facility has extermination service every month but for outside areas only. Facility staff have been spraying Raid bug spray and setting roach traps to treat the issue on their own, however, efforts have been unsuccessful. Based on LPA observation and evidence provided by a credible witness, the allegation of “staff do not ensure kitchen was free of pests” is deemed Substantiated at this time.

Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240816081953
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VALERIO RCFE
FACILITY NUMBER: 195850287
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2024
Section Cited
CCR
87555(b)(27)
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General Food Service Requirements (b)The following food service requirements shall apply: (27)All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
This requirement is not met as evidenced by:
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AD will ensure kitchen and refrigerators will be thoroughly cleaned and sanitized. AD will submit a plan for the next 3 months to ensure all regular and preventive professional treatments are taken. Administrator will submit proof to CCL by 08/30/2024.
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Based on LPA/credible witness observation and pictures obtained, the licensee did not comply with the section cited above as roaches and flies were observed in kitchen areas. This poses a potentail health and safety risk to persons 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3