197609643-5-9-2023-29-AS-BBAI-CRNUV2-20230509155424

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609643
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:55:08 PM

Document Has Been Signed on 05/09/2023 03:55 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VALERIO CASTLE INC		FACILITY NUMBER:	197609643
ADMINISTRATOR:	HAKOBYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	15360 VALERIO ST		TELEPHONE:	(310) 435-1445
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY: 4		CENSUS: 4	DATE:	05/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Anna Hakobyan - Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual. Upon arrival LPA met with Administrator Anna Hakobyan and explained the reason for the visit. The facility is One story. At 10am LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility has (4) private bedrooms. Room #2 is a designated staff room and LPA observed it to be empty and inaccessible to residents at this time. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. There is (1) bathroom in the common area designated for resident use. Bathroom nearest kitchen is designated as a staff restroom; The resident bathroom has a shower with non-skid materials and mat. The toilet and shower have grab bars. The hot water temperature was tested in the bathroom and the kitchen and was found to be within the range of 105F and 120F. Bathroom located in room # 5 is not in use and only accessible by Administrator at this time. Resident and staff records are stored in the locked entry way closet. Medications are centrally stored in this area as well. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were located in the kitchen / office area. No sharp objects or other dangerous items were observed in first aid kit at this time.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/09/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 809
Kitchen knives and sharp objects are stored in the top drawer to the right of the sink. LPA observed it to be inaccessible to residents in care. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in the garage inaccessible to residents in care. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room and dining area. At 11:15am, LPA observed a resident watching television in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. Fire extinguisher was observed fully charged and purchased in January 2023.

The laundry area is located in a space north of the kitchen. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in locked entry way closet. Extra incontinence supplies are stored in the entry closet as well. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout. The emergency telephone numbers are posted on a bulletin board in the entry way. Other required postings are posted near the entry and in living room as well.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/09/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 809-C
The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with table and chairs where residents can sit. The property is fenced on the left side of the home. The back and sides of the house are separated from the front yard by fence at the West side passageways. There is no gate to the driveway. There are no bodies of water on the premises at the present time. Garage is attached to the home and was observed to be inaccessible to residents in care. LPA observed the garage to store, emergency food supplies, extra non-perishable foods, PPE, medical supplies and incontinent supplies.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate at this time.
At approximately 11am, LPA interviewed (3) residents in care.
RECORDS: Records review began at 11:30 a.m.; four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were in order.
( 6) personnel records were reviewed for staff, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. The last Fire drill took place on 02/26/2023
At approximately 1:30pm, LPA interviewed (2) staff.
MEDICATIONS: Medications review began at 2:00pm The medications are centrally stored and locked in a closet in the hallway. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

During today’s visit, the LPA obtained copies of the following: staff roster, resident roster, Emergency Disaster Plan, and current liability insurance.

Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3