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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850287
Report Date: 01/21/2025
Date Signed: 01/21/2025 03:39:14 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
11/26/2024 and conducted by Evaluator Erica Mosley
COMPLAINT CONTROL NUMBER: 29-AS-20241126125851
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:
01/21/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Michael Custodio - Administraror DesigneeTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff do not keep the facility free of pest.
Staff do not provide adequate food service.
Staff do not ensure that sharp objects are inaccesible to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to the above facility. On today's visit at 2:30 p.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. The purpose of today’s visit is to deliver findings for the above allegations. Entrance interview.

On 11/26/2024, the Department received a complaint regarding the following allegations, Staff do not keep the facility free of pest, Staff do not provide adequate food service, and Staff do not ensure that sharp objects are inaccessible to residents in care.

(Report Continued on LIC 9099C...)(PAGE 1)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
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 5
Control Number 29-AS-20241126125851
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: 01/21/2025
NARRATIVE
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(Report Continued from LIC 9099...)(PAGE 2)
During the initial visit on 12/04/2024, visit LPA Mosley conducted a physical plant tour at 9:45 a.m. to ensure there were 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. LPA also interviewed five (5) out of six (6) residents, interviewed two (2) staff including the Administrator Designee and reviewed relevant documents pertaining to the investigation.

During today’s visit, LPA Mosley conducted a physical plant tour at 2:35 p.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations.

On the allegation Staff do not keep the facility free of pest it is the concern of the Reporting Party (RP) that pests are present in the kitchen. To investigate this complaint, LPA conducted a physical plant tour on 12/04/2024 and inspected the kitchen and food area. During the inspection the LPA did not actively observe any pests in the kitchen area, however witnessed one (1) cockroach walking along the floor adjacent to the dining table area in the kitchen area. Interviews with resident’s support that the facility has active cockroach activity, however pest control services are performed on a weekly, or biweekly basis. Interview with the Administrator Designee support that the facility has an active cockroach activity and are working with a pest control to address the issue. The Administrator Designee provided LPA with the recent report issued by the pest control company on the visit 11/23/2024 and have upcoming scheduled visits. Visits are scheduled on an as need basis where the facility schedules when they would like to be serviced. Based on the information obtained and interviews there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not keep the facility free of pest is deemed substantiated at this time.

On the allegation Staff do not provide adequate food service it is the concern of the Reporting Party (RP) that the facility is not properly dating food and food is expired. To investigate this complaint, LPA conducted a physical plant tour on 12/04/2024 and inspected the two (2) refrigerators and two (2) freezers in the kitchen area for proper labels and expiration dates. Inspection of the two (2) refrigerators and freezers revealed that there were a variety of items including two (2) undated, cooked bacon bits in a container, two (2) undated, cooked leftover meat in containers, and undated, cheese wrapped in foil paper. Furthermore, inspection revealed that food was not properly dated, stored or labeled posing an immediate health, safety or personal rights risk to persons in care.
(Report Continued on LIC 9099C PAGE 3...)
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20241126125851
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: 01/21/2025
NARRATIVE
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(Report Continued from LIC 9099C PAGE 2...) (PAGE 3)
LPA spoke to Administrator Designee about the importance of properly labeling and storing food. Administrator threw out the food that was not properly dated at the time of the visit. Based on LPA observation there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not provide adequate food service is deemed substantiated at this time.

On the allegation Staff do not ensure that sharp objects are inaccessible to residents in care it is the concern of the Reporting Party (RP) that the facility is not properly storing knives leaving them unattended and not locked. To investigate this complaint, LPA conducted a physical plant tour on 12/04/2024 and inspected the kitchen area and where the knives are located. Physical plant tour revealed that at 10:14 a.m. there was a knife unattended in the drying rack. At the time of the visit the LPA pointed out the knife to staff and it was immediately put away. LPA spoke to the Administrator Designee of the importance of keeping knives locked and inaccessible to persons in care. Based on LPA observation there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not ensure that sharp objects are inaccessible to residents in care is deemed substantiated at this time.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. 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: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20241126125851
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: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2025
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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Administrator agrees to have pet control conduct weekly treatments to reduce / remove pest activity and send proof to CCLD that treatments are scheduled and conducted.
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Based on LPA observation, the Licensee did not comply in the section cited above in that vermin was observed in the kitchen / dining room area on 12/04/2024 visit. This posed an immediate health and safety risk to persons in care.
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Type A
01/31/2025
Section Cited
CCR
87555(b)(9)(27)
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General Food Service Requirements
(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.
(28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.
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Administrator will conduct a full refrigerator and freeze audit and dispose anything that is expired or not dated by POC due date.
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Based on LPA observation, the Licensee did not comply in the section cited above in that multiple food items in the kitchen did not have proper dates and lables. This posed an immediate 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: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20241126125851
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: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2025
Section Cited
CCR
87309
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(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
(1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.
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Administrator will review the regulation cited and conduct a training with all staff and send proof to CCLD by POC due date.
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Based on LPA observation, the Licensee did not comply in the section cited above in that a knife was left out in the kitchen area accessible to residents in care. This posed an immediate 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: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5