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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850287
Report Date: 02/12/2025
Date Signed: 02/12/2025 04:17:06 PM

Document Has Been Signed on 02/12/2025 04:17 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: 5DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Michael Custodio - Administrator DesigneeTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:15 A.M. LPA met with Administrator Designee (AD) Michael Custodio. At 9:25 A.M. AD, contacted the Administrator by phone. At 9:32 A.M. LPA contacted administrator via phone and left a voicemail. At 9:38 A.M. Administrator, Francis Martit called LPA back stating that she won’t be able to join today’s visit and authorize AD to conduct today’s visit and sign reports. At 2:20 P.M. AD had to leave the facility authorizing caregiver, Jessica Leano to sign today’s report. Entrance interview conducted.

Beginning at 10:00 A.M. the LPA, along with AD toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers are fully charged and purchased on 04/08/2024. Hardwired smoke detectors and Carbon Monoxide detector were tested at 2:39 P.M. and all were functional at the time of the visit. No fire clearance concerns were observed.

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. LPA conducted a review of expiration dates on product labels. Cleaning supplies are locked and inaccessible to residents in care. Sharps are located in the medication locked cabinet. At 10:50 A.M. hot water measured 127.5 degrees Fahrenheit. AD stated that staff does not have access to a thermometer for measuring hot water. Instead, staff currently rely on using their hands to gauge the water’s heat. LPA explained that this practice does not provide an accurate reading and it is a safety risk to residents in care.



Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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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Document Has Been Signed on 02/12/2025 04:17 PM - It Cannot Be Edited


Created By: Valeria Conway On 02/12/2025 at 03:12 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: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having hot water temperature above regulation range which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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Administrator change gage on the thermostast during today's visit. Administrator agrees to submit a 7 day temperature log by 2/20/2025 to LPA.
Type A
Section Cited
CCR
87465(i)(1-4)
(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed. (4) The date of destruction. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews and record review, the licensee did not comply with the section cited above by have discontinued medication for former and current residents inside a staff room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2025
Plan of Correction
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Administrator designee contacted pharmacy during today's visit to schedule an appoiment to pick up all discontinued medication. Once done, administrator will submit a destruvtion log to LPA before POC due 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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/12/2025 04:17 PM - It Cannot Be Edited


Created By: Valeria Conway On 02/12/2025 at 03:25 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: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by having discrepancies in 4 out of 4 resident's medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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ALL staff shall be re-trained on how to administer, dispense and store medication. Keep documentation of refusal. Administrator agrees to submit in-service training and create a refusal log
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALERIO RCFE
FACILITY NUMBER: 195850287
VISIT DATE: 02/12/2025
NARRATIVE
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Continued from LIC 809-C

COMMON AREAS: This includes the living room and dining room areas. LPA observed common areas to be clean and properly furnished at the time of the visit. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed.

BATHROOMS: There are two (2) shared bathrooms for resident use, one (1) for visitors and one (1) for staff use only. Resident's restrooms were observed to be equipped with slip resistant surfaces and contain slip resistant mats. Grab bars were observed in the bathrooms. Between 10:36 A.M and 10:45 A.M., the hot water temperature was measured in both shared resident bathroom and measured 121.2- and 127.1-degrees Fahrenheit.

BEDROOMS: There are nine (9) bedrooms in total. Including three (3) staff room and six (6) private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. LPA observed full medication containers belonging to former and current residents inside staff room #1 (S1). AD stated that some residents had changed pharmacies and confirmed that discontinued medication should have been disposed of.

OUTDOOR SPACE: The perimeter of the facility is fenced. The front yard is free of obstructions. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises at the time of the visit. LPA observed a back house. AD stated that property is part of the facility and being rented to a Private Individual (PI). A Guardian system check for criminal background clearance was conducted on PI and they are fingerprinted and associated to the facility.

GARAGE: Garage is attached to the main house and inaccessible to the residents in care. Garage contained extra beds, extra mobility devices, PPE and incontinence supplies, and emergency food and water.


Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALERIO RCFE
FACILITY NUMBER: 195850287
VISIT DATE: 02/12/2025
NARRATIVE
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Continued from LIC 809-C

RECORD REVIEW: Between 11:37 A.M. and 1:05 P.M. staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Five (5) resident files were reviewed. LPA observed that Resident #1 (R1) is unwilling to provide her personal information including date of birth and refuse to sign all documentation provided by the facility. Six employee (6) files were reviewed, five (5) staff files and one (1) private individual living in the back hose. All files were observed to contain all required documents.

MEDICATION REVIEW: Per AD, no resident are refusing medication. Medications review began at 1:15 P.M. Medications for four (4) residents were observed. Medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are documented on the centrally stored medications and destruction record for all five (5) residents. The following was observed: LPA observed a piece of tape on Resident #1’s (R1s) Banophen 25 MG (take 1 tablet at bedtime) cap. On it “PRN” was written by staff. AD stated that physician had discontinued this medication, however, they were unable to provide documentation from the resident’s primary physician confirming the discontinuation. Resident #2 stores their own medication in a locked box inside their private room (Room #1). The LPA reviewed R2’s physician’s report to verify that they are able to self-administer their medication. After confirming this information, the LPA did not assess medication compliance for R2 during today’s visit. Furthermore, Resident #3s’ (R3s) Olanzappine and Dicalproex Sod ER 500 mg are not being given accordingly. Olanzapine (take 1 tablet at bedtime) which was opened on 02/07/2025, showed that only six (6) pills had been administered. Additionally, Divalproex Sod ER 500 mg which was opened on 02/08/2025 (take 1 tablet at bedtime), indicated that only two (2) pills had been given.



Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALERIO RCFE
FACILITY NUMBER: 195850287
VISIT DATE: 02/12/2025
NARRATIVE
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Continued from LIC 809-C

Lastly, Resident #4 (R4) has two (2) bubble packs of montelukast SOD 10 mg (take 1 tablet daily) with fill dates of 10/01/2024 and 10/09/2024. Upon review, the LPA observed that one pack was opened on 11/01/2024 and missing 14 pills, while the second pack remained unopened. AD was unable to confirm whether the medication is still prescribed or has been discontinued, as R4 is responsible for self-administering their prescription medication. Aditionally, AD stated that R4 frequently leaves the facility without taking their medication, however, staff does not have documentation of these occurrences.

Additionally, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. Emergency disaster drills are conducted quarterly, with the last drill conducted on 11/20/2024.

LPA requested the following documents, Personnel Roster LIC (500), Liability Insurance, and Resident Roster.

INTERVIEWS: During today's visit, LPA interviewed one (1) staff and one (5) residents.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.)

Exit interview conducted. A copy of today's report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
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