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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609643
Report Date: 11/08/2021
Date Signed: 11/08/2021 12:55:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/04/2021 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20211104122839
FACILITY NAME:VALERIO CASTLE INCFACILITY NUMBER:
197609643
ADMINISTRATOR:HAKOBYAN, ANNAFACILITY TYPE:
740
ADDRESS:15360 VALERIO STTELEPHONE:
(310) 435-1445
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:4CENSUS: 4DATE:
11/08/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Anna Hakobyan TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff is not wearing PPE

Staff mishandled medication while residents are in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint investigation for the above allegations. LPA met with Administrator Anna Hakobyan and explained the reason for the visit.

At 11:30am LPA conducted physical plant, interviewed staff and residents. LPA also reviewed and obtained copies of pertinent documents relevant to the investigation.

Regarding the allegation that staff is not wearing PPE, Licensing received information that Staff 1 (S1) was witnessed not wearing a mask on (2) separate dates. LPA interview with Administrator confirmed the above information. Administrator stated they have since had a discussion with staff and staff will continue to follow CCLD mask guidance. LPA interview with (2) residents revealed that all residents have witnessed all staff wearing masks while caring for residents. LPA observed (3) staff on duty wearing masks during the visit. Based on information gathered during this visit, the department has sufficient evidence to determine that facility staff is not wearing PPE. Therefore the allegation is SUBSTANTIATED at this time.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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 3
Control Number 29-AS-20211104122839
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALERIO CASTLE INC
FACILITY NUMBER: 197609643
VISIT DATE: 11/08/2021
NARRATIVE
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Continued from 9099

Regarding the allegation that staff mishandled medication while residents are in care, Licensing received information that S1, S1's prescribed medication was accessible to residents in care. S1's medication was stored  in a prescription bottle on a bedside table in an unlocked staff designated bedroom. LPA interview with Administrator confirmed the incident did occur. Administrator stated that S1's medications are typically stored inside a marked storage box designated for staff in a locked medication closet. Based on information gathered during this visit, the department has sufficient evidence to determine that the staff mishandled medication while residents are in care. Therefore the allegation is SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20211104122839
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALERIO CASTLE INC
FACILITY NUMBER: 197609643
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in all Facilities:..To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator agreed to immediately implement mask wearing in the facility. Conduct training on Mask/Infectious Disease Prevention with all staff. Administrator agreed to provide training records with all staff signatures to CCLD via email by 11/09/2021.
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Based on information that Licensing received S1 was witnessed without wearing their mask on (2) separate dates. LPA interview with Administrator confirmed S1 was witnessed without wearing their mask. This poses as an immediate health and safety risk to residents in care.
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Type B
11/08/2021
Section Cited
CCR
87465(h)(2)
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87465 (h)(2) Incidental Medical and Dental Care - Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by:
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POC cleared during the visit. Administrator provided documentation of in service training regarding how to properly store medications with staff that occurred on 10-27-2021.
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Based on information that Licensing received, S1's prescribed medication was accessible to residents in care. S1's medication was stored  in a prescription bottle on a bedside table in an unlocked staff designated bedroom. This poses as a potential health and safety risk to residents 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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3