195850287-12-4-2024-29-AS-KLOZ-DCFUKU-20241230143942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850287
Report Date: 12/04/2024
Date Signed: 12/04/2024 06:39:47 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
08/09/2023 and conducted by Evaluator Erica Mosley

COMPLAINT CONTROL NUMBER: 29-AS-20230809161001

FACILITY NAME:	VALERIO RCFE		FACILITY NUMBER:	195850287
ADMINISTRATOR:	DONOVAN, KOHL		FACILITY TYPE:	740
ADDRESS:	14315 VALERIO ST		TELEPHONE:	(747) 264-0505
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 6	DATE:	12/04/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Michael Custodio - Admin Designee		TIME COMPLETED:	06:45 PM

ALLEGATION(S):

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Staff is mismanaging resident's medications.
Staff do not properly store and dispose facility food.
Facility roof is in disrepair.
Facility floor is in disrepair.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

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 8

Control Number 29-AS-20230809161001

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: 12/04/2024

NARRATIVE

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(PAGE 2) Report Continued from LIC9099....
On todays visit LPA Mosley conducted a physical plant tour at 9:45 a.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. At 10:04 a.m. LPA and Administrator Designee inspected food items in the two (2) refrigerators and two (2) freezers in the kitchen area to check for proper labels and expiration dates, at 10:44 a.m. conducted a medication audit on all six (6) residents, At 11:30 a.m. conducted an audit on facilities P&I records of the four (4) residents receiving P&I funds, from 11:49 a.m. – 1:15 p.m. Interviewed five (5) out of six (6) residents, from 1:20 p.m. – 2:00 p.m. interviewed two (2) staff including the Administrator Designee and reviewed relevant documents pertaining to the investigation.
On the allegation Staff is mismanaging resident's medications it is the concern of the Reporting Party (RP) that the facility staff are mismanaging residents’ medication including Resident #1 and Resident #6. To investigate this complaint, LPA conducted a medication audit on all six (6) residents. Medication audit revealed that medications are centrally stored and locked inaccessible to residents in care in a kitchen cabinet. The audit revealed that the facility was not accurately documenting the medication start dates on the Centrally Stored and Medication Record for six (6) out of six (6) residents which poses a potential health and safety risk to residents in care. LPA and Designee discussed the importance of record keeping and the potential health and safety risk in not adding accurate start dates. Based on information obtained, and medication audit there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff is mismanaging resident's medications is deemed substantiated at this time.
On the allegation Staff do not properly store and dispose facility food it is the concern of the Reporting Party (RP) that the facility staff are not properly storing and disposing facility food including not labeling food properly. To investigate this complaint, LPA inspected food items in the two (2) refrigerators and two (2) freezers in the kitchen area to check for proper labels and expiration dates. Inspection revealed that the facility had multiple items that were not properly dated including two (2) containers of left over food, two (2) containers of cooked bacon, along with cheese wrapped up in foil paper and various frozen vegetables in bags which poses a potential health and safety risk to residents in care. LPA and Administrator Designee spoke about the importance of proper documentation when putting items in the refrigerator and freezer. Based on information obtained, and food inspection there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not properly store and dispose facility food is deemed substantiated at this time.
Report Continued on LIC 9099C PAGE 3...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 29-AS-20230809161001

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: 12/04/2024

NARRATIVE

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(PAGE 3) Report Continued from LIC9099....
On the allegation Facility roof is in disrepair it is the concern of the Reporting Party (RP) that the right side of the facility roof is in disrepair causing a potential hazard to residents in care. To investigate this complaint, LPA conducted a physical plant tour to ensure the safety of residents in care. Plant tour revealed that the right side of the facility’s roof awning has an open area at the end that is not covered however, the beams are intact along with the rest of the roof. The awning is cosmetic and does not hinder the safety of the residents. Interview with the Administrator Designee revealed that they did have a piece of the of the roofs awning that was used for shade but was removed for safety. It was noted that the roof itself is not in disrepair, but the awning has a piece that was removed for safety. LPA did not observe any potential hazards with the roof or the awning at the time of the visit. However, based on interview with the Administrator designee confirm that last year the roof awning was in disrepair is sufficient evidence to support the allegation occurred. Therefore, the allegation of Facility roof is in disrepair is deemed substantiated at this time.

On the allegation Facility floor is in disrepair it is the concern of the Reporting Party (RP) that part of the floor covering in the hallway is in disrepair causing a potential hazard to residents in care. To investigate this complaint, LPA conducted a physical plant tour to ensure the safety of residents in care. Plant tour revealed that the hallway has an area that has visibly had wood tiles replaced. LPA did not observe any potential hazards with the floor at the time of the visit. Interviews with staff revealed that the wood tiles were coming loose however were replaced in a timely manner. Based on interview with the Administrator Designee stating last year the floor was in disrepair is sufficient evidence to support the allegation occurred. Therefore, the allegation of Facility floor is in disrepair is deemed substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 8

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
08/09/2023 and conducted by Evaluator Erica Mosley

COMPLAINT CONTROL NUMBER: 29-AS-20230809161001

FACILITY NAME:	VALERIO RCFE		FACILITY NUMBER:	195850287
ADMINISTRATOR:	DONOVAN, KOHL		FACILITY TYPE:	740
ADDRESS:	14315 VALERIO ST		TELEPHONE:	(747) 264-0505
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 6	DATE:	12/04/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Michael Custodio - Admin Designee		TIME COMPLETED:	06:45 PM

ALLEGATION(S):

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Staff do not dispose expired medications.
Staff is not safe guarding resident's personal belongings.
Staff is mismanaging resident's money.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Erica Mosley conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 08/11/2023 by LPA Christine Yee. On today's visit at 9:40 a.m., LPA Mosley was greeted by staff and Administrator Designee and informed them of the visit. LPA met with Administrator Designee, Michael Custodio and explained the reason for the visit. Entrance interview.

On 08/09/2023, the Department received a complaint regarding the following allegations, Staff do not dispose expired medications, Staff is not safeguarding resident's personal belongings, and Staff is mismanaging resident's money.

Report Continued on LIC 9099C PAGE 2...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 29-AS-20230809161001

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: 12/04/2024

NARRATIVE

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(PAGE 2) Report Continued from LIC9099A....

During the initial visit on 08/11/2023, LPA Yee reviewed medications at 10:40am, toured the facility, inside and outside at 12:28 pm, reviewed facility records at 12:50pm, interviewed Resident #1 at 1:25pm and ensured there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations.

On todays visit LPA Mosley conducted a physical plant tour at 9:45 a.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. At 10:04 a.m. LPA and Administrator Designee inspected food items in the two (2) refrigerators and two (2) freezers in the kitchen area to check for proper labels and expiration dates, at 10:44 a.m. conducted a medication audit on all six (6) residents, At 11:30 a.m. conducted an audit on facilities P&I records of the four (4) residents receiving P&I funds, from 11:49 a.m. – 1:15 p.m. Interviewed five (5) out of six (6) residents, from 1:20 p.m. – 2:00 p.m. interviewed two (2) staff including the Administrator Designee and reviewed relevant documents pertaining to the investigation.

On the allegation Staff do not dispose expired medications it is the concern of the Reporting Party (RP) that the facility staff are not disposing residents expired medication. To investigate this complaint, LPA conducted a medication audit on all six (6) residents. Medication audit revealed that medications are centrally stored and locked inaccessible to residents in care in a kitchen cabinet. The audit revealed that all six (6) residents’ medications are unexpired. Staff interviews revealed that they are unaware of any medication being expired at the facility. Furthermore, staff deny ever having any medications that are expired at the facility. Record review revealed that all staff have proper training regarding medication. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not dispose expired medications is deemed unsubstantiated at this time.

Report Continued on LIC 9099C PAGE 3...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 29-AS-20230809161001

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: 12/04/2024

NARRATIVE

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(PAGE 3) Report Continued from LIC9099 PAGE 2....
On the allegation Staff is not safeguarding resident's personal belongings it is the concern of the Reporting Party (RP) that the facility staff are not safeguarding residents’ personal belongings including Resident #2 (R2) personal food items. To investigate this complaint, LPA conducted interviews with five (5) residents including R2 and two (2) staff interviews. Resident interviews revealed that they have not had any issues with their personal belongings not being safeguarded by the facility. They feel the facility keeps their belongings safe and have not experienced any issues or things going missing. Interview with R2 revealed that they have not had any issues any of their personal items not being safeguarded by the facility. They have not had any of their personal belongings including food taken or gone missing at the facility. Staff interviews revealed that staff ensure resident’s personal belongings are safeguarded. Staff are unaware of any resident having issues with personal belongings going missing. Furthermore, staff deny having any knowledge or taking any personal belongings of a resident. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff is not safeguarding resident's personal belongings is deemed unsubstantiated at this time.

On the allegation Staff is mismanaging resident's money it is the concern of the Reporting Party (RP) that the facility staff mismanaging residents’ money including R1 and not having accurate documentation. To investigate this complaint, LPA conducted an audit on the facilities P&I records of the four (4) residents receiving P&I funds, interviewed three (3) out of four (4) residents receiving P&I funds. The fourth (4) resident was unavailable at the time of the visit. Interviewed the Administrator Designee who handles the facilities P&I funds. The audit revealed that the facility has accurate documentation of when funds are received and distributed to the residents. The facility does not handle the residents’ funds past distributing. All four (4) residents handle their finances and do not have the facility managing or storing their funds past distribution. Interviews with three (3) out of four (4) residents revealed that the facility accurately distributes their P&I funds and documents every time funds are distributed. Residents have not had any issues with their funds being withheld or unaccounted purchases on their behalf. Interview with R1 revealed that they have not had any issues with their P&I or with staff purchasing items on their behalf. R1 stated they handle their money and spend it as they choose. R1 stated they have not experienced staff purchasing items on their behalf. Interviews with staff revealed that staff do not handle residents’ funds beyond distributing the funds when received. Staff deny and are unaware of purchasing items for any resident including R1 on their behalf. Staff do not purchase items for residents only assist if needed and requested by residents. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff is mismanaging resident's money is deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 29-AS-20230809161001

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: 12/04/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/25/2024 Section Cited CCR 87465(H)(6)a-e	1 2 3 4 5 6 7	(h)The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes....	1 2 3 4 5 6 7	Licensee will request training from a professional entity to provide medication training and conduct a medication audit on all medications.
	8 9 10 11 12 13 14	Based on records review, and medication audit the licensee did not comply with section cited above as in six (6) out of six (6) residents did not have the start dates documented on the centrally stored log.	8 9 10 11 12 13 14	Licensee will update centrally stored medication log and submit paperwork as proof to CCL/LPA indicating the training, audit and updated centrally stored was completed.Submit proof to LPA/ CCLD by POC date.
Type B 12/25/2024 Section Cited CCR 87555(b)(9)	1 2 3 4 5 6 7	General Food Service Requirements. Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.	1 2 3 4 5 6 7	Licensee/Administrator agreed to provide in-service training to staff regarding food storage (labeling and dating). Submit written self certification that in-service was completed and ensure proper food storage procedures are followed.
	8 9 10 11 12 13 14	Based on observation the licensee did not comply with section cited above as Food items observed in refrigerator were in containers and bags with no lable or date to esure the nutritive values of food.	8 9 10 11 12 13 14	Licensee agreed to go through both refrigerators and ensure all items are dated and labeled by POC date.

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: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 29-AS-20230809161001

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: 12/04/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/04/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	The facility has corrected / fixed the roof.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: facility roof awning was in disrepair. The Facility floor was in disrepair.	8 9 10 11 12 13 14	The facility has corrected / fixed the floor.
	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.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC9099 (FAS) - (06/04)

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