<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850287
Report Date: 08/20/2024
Date Signed: 08/20/2024 03:04:46 PM

Document Has Been Signed on 08/20/2024 03:04 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VALERIO RCFEFACILITY NUMBER:
195850287
ADMINISTRATOR/
DIRECTOR:		DONOVAN, KOHLFACILITY TYPE:
740
ADDRESS:14315 VALERIO STTELEPHONE:
(747) 264-0505
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 6DATE:
08/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:32 AM
MET WITH:Michael CustodioTIME VISIT/
INSPECTION COMPLETED:
03:30 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) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 2 29-AS-20240816081953). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation.

During the visit on 08/20/2024, LPA observed expired food items in the pantry and refrigerator and unlabeled food items stored without original packaging and labels detailing nutritive values and expiration dates between 09:40AM-10:00AM. At 10:06AM, LPA observed cleaning solutions, chemicals and hazardous items stored unlocked in visitor bathroom, which is accessible to residents in care. At 10:09AM, LPA observed surveillance cameras in common areas. Interview with AD revealed that the cameras have an audio component. At 10:20AM, LPA observed resident bedrooms to contain trash bins without tight fitted lids. During the visit, LPA observed smoke detector chirping throughout the facility. Hardwired combination smoke and carbon monoxide detector was tested at 10:33AM and was functional and operating during the time of the visit.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were 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
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 4
Document Has Been Signed on 08/20/2024 03:04 PM - It Cannot Be Edited


Created By: Angela Barutyan On 08/20/2024 at 12:00 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: 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
08/27/2024
Section Cited
CCR
87555(b)(8)

1
2
3
4
5
6
7
(b) The following food service requirements shall apply: (8)All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Staff discarded expired food items during time of the visit. POC is cleared.
8
9
10
11
12
13
14
Based on LPA observation, the Licensee did not comply with the section cited above. LPA observed expired food items in pantry and refrigerator dating back to 11/17/2022. This posed a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Type B
08/27/2024
Section Cited
CCR87555(b)(9)

1
2
3
4
5
6
7
(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:
1
2
3
4
5
6
7
Administrator will provide general food service requirements training to staff and will submit training logs as well as a signed and dated statement of understanding of the section to CCL by 08/27/2024.
8
9
10
11
12
13
14
Based on LPA observation, the Licensee did not comply with the section cited above. LPA observed food items stored without original packaging and labels detailing nutrtitive values and expiration dates. This poses a potental health and safety risk to persons in care.
8
9
10
11
12
13
14
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: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


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/20/2024 03:04 PM - It Cannot Be Edited


Created By: Angela Barutyan On 08/20/2024 at 12:25 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: 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
08/27/2024
Section Cited
CCR
87309(a)

1
2
3
4
5
6
7
Storage Space(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Staff stored cleaning solutions inaccessible to residents in care during the time of the visit. POC is cleared.
8
9
10
11
12
13
14
Based on LPA observation, the Licensee did not comply with the section cited above in that cleaning solutions were stored accessible in the visitor bathroom which posed a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Type B
09/03/2024
Section Cited
CCR87468.1(a)(1)

1
2
3
4
5
6
7
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
AD will unplug the cameras until the Licensee can confirm that the cameras do not record audio and will submit a statement detailing if cameras have or do not have an audio system. AD will replace the cameras to a non-audio system if found to record audio and will submit proof to CCL .
8
9
10
11
12
13
14
Based on observation and interviews, the Licensee did not comply with the section cited above in that cameras in the common areas have an audio component which poses a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
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: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


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/20/2024 03:04 PM - It Cannot Be Edited


Created By: Angela Barutyan On 08/20/2024 at 12:31 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: 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
08/30/2024
Section Cited
CCR
80088(f)(1)

1
2
3
4
5
6
7
Solid waste shall be stored, located and disposed of in a manner that will not...provide a breeding place or food source for insects or rodents. (1)All containers, including movable bins, used for storage of solid wastes....shall have tight fitted lids...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
AD will either buy lids for the trash bins or replace the trash bins to be lidded. AD will submit proof to CCL by 08/30/2024.
8
9
10
11
12
13
14
Based on LPA observation, the Licensee did not comply in the section cited above in that resident bedrooms were observed to contain trash bins without lids. This poses a potential health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: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


LIC809 (FAS) - (06/04)
Page: 4 of 4