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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850287
Report Date: 02/25/2026
Date Signed: 02/25/2026 06:28:13 PM

Document Has Been Signed on 02/25/2026 06:28 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: 4DATE:
02/25/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Michael Custodio, Administrative DesigneeTIME VISIT/
INSPECTION COMPLETED:
06:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Jessica Leano, Staff. Today's visit was conducted with Michael Custodio, Francis Martir, Administrator did not participate in today's visit due to a prior commitment. The reason for today's visit was provided.

The facility is a single storey building consisting of a kitchen, dining room, living room, 9 bedrooms of which 3 bedrooms located in the front are used for live-in staff, an attached garage and detached back house was previously rented and is currently vacant. A copy of the building permit was requested for the back house. The facility is fire-cleared for 3 AMBULATORY in bedroom #3 and bedroom #4, 2 NON-AMBULATORY in bedroom #1 and bedroom #2 and 1 BEDRIDDEN resident in bedroom #5. The home has an approved hospice waiver for 6 residents.

On today's visit the only domain reviewed on the CARE Inspection Tool was the Incidental Medical and Dental domain, 4 resident files and medications for Resident #2, Resident #3 and Resident #4 were reviewed. Resident #1's medication was not reviewed as the resident retains their own medications in their own room in a locked plastic box. The following was noted:
  • Residents #1, #2 and #4 have not received an annual medical assessment
  • Resident #3 does not have any evidence of a TB test
  • Resident #3 and Resident #4 are prescribed PRN medications but there were no completed PRN


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2026
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 02/25/2026
NARRATIVE
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Page 2.
  • Authorization Letters observed in their files
  • Resident #1 does not have a current Appraisal/Needs and Services(ANS). The last assessment was done April 2024.
  • per review of Resident #2, Resident #3 and Resident #4's medications, the medications in the bubble packs do not match the medications that were dispensed. Medications noted as being dispensed on the Medication Administration Record(MAR) were still observed in the bubble pack. Evening medications noted for the evening were dispensed in the morning. Medications from the bubble pack were missing from today(2/25/26 through 2/28/26 were missing. The MAR log for Resident #1, who is hospitalized from the evening of 2/24/26 and still in the hospital as of today's visit, indicate that their medications were dispensed. Medications are dispensed once a day when the label on the bubble pack indicates it is to be dispensed twice a day.
  • The facility does not have copies of the physician's orders for the centrally stored medications.


Due to the difficulty in obtaining facility files and the issues with the medications all the other domains of the CARE Inspection Tool could not be reviewed. A return visit is needed to complete the required annual inspections. Any citations not addressed on today's visit will be addressed on the return visit.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 18.

Exit interview was conducted, APPEALS RIGHTS discussed and a copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/25/2026 06:28 PM - It Cannot Be Edited


Created By: Christine Yee On 02/25/2026 at 05:00 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: 02/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as per record review, the facility does not have any physicians orders in the residents' files for all the centrally stored medications ] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2026
Plan of Correction
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The Licensee will contact all the prescribing physicians and obtain physicians orders for all the centrally stored medications in the Residents' files by 3/4/26
Type A
Section Cited
CCR
87465(c)(2)
87465 Incidental Medical and Dental Care
(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 and record review, the licensee did not comply with the section cited above as medications reviewed show that the facility is not dispensing the medications as prescribed by the physician. MAR LOGS indicate medications are dispensed and is still in the bubble pack and medications are dispensed in amounts not indicated on the medication label] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2026
Plan of Correction
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Licensee will schedule medication training with a pharmacist or a medical professional qualified to conduct medication training. Evidence of the training will be maintained in the staff files. Licensee will also conduct weekly medication reconciliation and document in writing the results of the review by 3/4/26. Fax evidence of training with the name, address and telephone number of the instructor to the Department by 3/4/26 for verification..
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/25/2026 06:28 PM - It Cannot Be Edited


Created By: Christine Yee On 02/25/2026 at 05:00 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: 02/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(b)
Incidental Medical and Dental Care Services
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as Resident #3 and Resident #4 take PRN medications but there is no completed PRN Authorization Letters observed in the residents' files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2026
Plan of Correction
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Licensee will contact the prescribing doctor and obtain completed PRN Authorization Letters for Resident #3 and Resident #4 and any other resident who has PRN medications and maitain them in their files
Type B
Section Cited
CCR
87463(h)
87463 Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above ias records reviewed reviewed, Resident #1, Resident #2 and Resident #4 have not had an annual routine visit with a licensed medical professional since 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2026
Plan of Correction
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Licensee will schedule appointments with the Residents physician and let the Department know when the appointments have been scheduled for and inform the Department by 3/4/26 and notiify the Departmetn when the visit has been completed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2026


LIC809 (FAS) - (06/04)
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