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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802280
Report Date: 01/26/2024
Date Signed: 01/26/2024 10:23:24 AM

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
11/01/2023 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20231101111334
FACILITY NAME:C.A.L.L. - VALDEZ HOUSEFACILITY NUMBER:
405802280
ADMINISTRATOR:KYLAN REYNOSOFACILITY TYPE:
740
ADDRESS:4305 VALDEZ AVETELEPHONE:
(805) 460-6663
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:4CENSUS: 4DATE:
01/26/2024
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Administrator - Kyland Reynoso announced TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Due to insufficient staffing residents’ needs are not met.
Staff do not have proper training.
Facility has mold.
INVESTIGATION FINDINGS:
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 At 8:30am on 01/26/2024, Licensing Program Analyst (LAP) Jeffries arrived unannounced at the facility to issue final findings to this complaint. LPA met with Administrator, Kyland Reynoso announced who he is and the reason for the visit. LPA issued final findings on a separate complaint for this facility on this same visit.

As to the allegation of, “Due to insufficient staffing resident’s needs are not met.” and “Staff do not have proper training. “It was alleged that resident’s needs were not being met during the AM shifts in the months of September and October 2023. It was discovered through documentation, and interviews that on as many as 15 A.M. shifts, according to documentation (09/07, 09/08, 09/12, 09/13, 09/14, 09/15, 09/26, 09/28, 09/29, 10/03, 10/05, 10/06, 10/17, 10/20, 10/24, and 10/25. All dates in 2023) between September and October 2023, Staff 1 (S1) had not met the regulations requirements of training to work without shadowing a tranined staff. According to interview by LPA on 11/02/2023 with S1, S1 was left alone with residents in care for which required residents transition from sleeping to getting ready to leave the facility for day program.
CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
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 6
Control Number 29-AS-20231101111334
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: C.A.L.L. - VALDEZ HOUSE
FACILITY NUMBER: 405802280
VISIT DATE: 01/26/2024
NARRATIVE
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Records reviewed and collected on 11/02/2023 show that 1 of 4 residents have a diagnosis of dementia, and 4 of 4 residents require assistance in bathing, 1 of 4 are not able to bath themselves, as indicated residents Physician Orders (LIC602). On 11/02/2023 LPA Jeffries requested in report LIC9099, the following: “All staff of Facility, actual hours worked September - October 2023, -Job descriptions and job duties, -All staff training past 12 months. …” Facility Administrator only provided training for one staff (S1). The training records provide for S1 indicated the following training: Drivers Training 08/09/23, 1.5 hours, Med assist training 08/04/23, 4.5 hours, Orientation 07/28/23 5 hours, CPI (Crisis Prevention Institute) Online 09/23/23, 2.5 hours, CPI In-person, 09/23/23 6.25 hours. LPA noted that there was no indication of basic first aid, CPR (Cardio-Pulmonary Resuscitations), or dementia training for S1. On 01/25/2024 at 4:46PM, Executive Director, Sean Denich emailed LPA Jeffries with additional documentation which did not show any additional training for S1. Additionally, facility time records for the same months showed no different compelling findings than the original time sheet documents submitted at the beginning of this investigation. LPA conducted an interview with S1 on 11/02/2023, where S1 stated that they have been left alone with residents without any training for several days and some residents left for day programs without having time to eat breakfast. Based on documentation, and interviews, the allegations of, “Due to insufficient staffing resident’s needs are not met.” and “Staff do not have proper training. “ and both are substantiated at this time.

As to the allegation of, “Facility has mold.” It was alleged that the facility had dangerous mold in the on-suite bathroom. On 11/02/2023 LPA Jeffries observed and photographed black mold on the bathroom vanity in facilities on-suite bathroom. LPA noted that before LPA to make the observation, facility maintenance personal S4, was observed walking out of the facility with two hands full of molded wallpaper, which matched the remnants of the wallpaper that was in the bathroom vanity. LPA noted that mold mediation was started on this date (11/02/2023). LPA interviewed S1 on 11/02/2023. S1 stated that they had reported the mold to the facility Administrator during the first week of September 2023. Based on observations, photographs, interviews, and mold mitigation efforts during the visit, there is enough evidence to support the allegation of, “Facility has mold.” and the allegation is substantiated at this time.

Exit interview, report read, citations issued, appeal rights and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20231101111334
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: C.A.L.L. - VALDEZ HOUSE
FACILITY NUMBER: 405802280
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2024
Section Cited
HSC
1569.626(a)(1)
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1569.626 Training requirements for direct care staff (a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff:(1) Twelve hours of dementia care
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Facility shall provide a list of all facility personnel and their training records to LPA within 24 hours of this report. Then formulate a training schedule that will have all facility personnel properly trained by regulation standards within two weeks of this report.
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training, six of which shall be completed before a staff member begins working independently with residents, … This requirement was not met by S1 being left alone and not properly trained, which poses an immediate danger to residents in care.
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Type B
01/29/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. This requirement was not met by evidence of time sheets and interviews that on at least
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Facility will create a more robust staff recruitment campaign, outlining additional steps the facility will take to recut more numbers and qualified staff then the current recruitment tools the facility employes. this recruitment campaign will be emailed to LPA by 02/09/2024
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 5 to 15 occasions there was only one staff without basic regulated training was on shift during 7am to 10am which puts resident in immediate danger.
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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: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 29-AS-20231101111334
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: C.A.L.L. - VALDEZ HOUSE
FACILITY NUMBER: 405802280
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2024
Section Cited
CCR
87303(a)(1)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.(1) Floor surfaces in bath,
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Mold mitigation was started on 11/02/2023, LPA confirmed with photographs that mold mitigation was started. LPA was sent photographs of KILLZ paint applied to vanity. LPA was told by Executive Director that vanity would eventually be replaced. This POC is cleared and new LPA will follow up.
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 laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met by evidence of black mold in the bathroom which poses an immediate danger 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: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
11/01/2023 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20231101111334

FACILITY NAME:C.A.L.L. - VALDEZ HOUSEFACILITY NUMBER:
405802280
ADMINISTRATOR:KYLAN REYNOSOFACILITY TYPE:
740
ADDRESS:4305 VALDEZ AVETELEPHONE:
(805) 460-6663
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:4CENSUS: 4DATE:
01/26/2024
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Administrator - Kyland Reynoso announced TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not provide medical attention to residents in a timely manner.
Staff did not assist residents with obtaining medical appointments.
INVESTIGATION FINDINGS:
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 As to the allegations of, “Staff did not provide medical attention to residents in a timely manner.” and Staff did not assist residents with obtaining medical appointments.” It was alleged that R1 had been complaining of pain that was not addressed in ‘early’ October (2023). It was discovered through interviews and documentation that, R1 on 09/07/2023, had a wellness visit with Primary Care Physician, addressing all R1’s pain complaints; on 09/12/2023, R1 had eye exam; on 10/02/2023, R1 went to the Emergency Room to address pain and stayed overnight in the hospital. On 10/16/2023, R1 went to the hospital again for pain and was hospitalized until 10/20/2023; on 10/21/2023 R1 returned to the hospital as instructed by Home Heath Care Nurse. LPA interviewed S2 on 11/02/2023, S2 stated that R1 has been having pain with urinating and is being addressed by medical professionals and staff were following instructions from ER visits and Home Health Care Nurse. S1 stated they have always addressed R1’s medical needs in a timely manner.

CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20231101111334
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: C.A.L.L. - VALDEZ HOUSE
FACILITY NUMBER: 405802280
VISIT DATE: 01/26/2024
NARRATIVE
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 Based on documentation, and interviews, there is not enough evidence to support the allegations of, “Staff did not provide medical attention to residents in a timely manner.” and “Staff did not assist residents with obtaining medical appointments.” and are both unsubstantiated at this time.

Exit interview, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6