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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802280
Report Date: 05/21/2024
Date Signed: 05/21/2024 04:24:35 PM

Document Has Been Signed on 05/21/2024 04:24 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:C.A.L.L. - VALDEZ HOUSEFACILITY NUMBER:
405802280
ADMINISTRATOR/
DIRECTOR:		KYLAN REYNOSOFACILITY TYPE:
740
ADDRESS:4305 VALDEZ AVETELEPHONE:
(805) 460-6663
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 4CENSUS: 4DATE:
05/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Kylan Reynoso, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a case management visit to the facility above. LPA met with Kylan Reynoso and explained the purpose of the visit.

During a complaint investigation LPA learned the facility has a current resident with dementia.
The facility does not have an approved Plan of Operation with a Program Plan for Dementia residents.

Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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 05/21/2024 04:24 PM - It Cannot Be Edited


Created By: Rachael De Leon On 05/21/2024 at 03:57 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: C.A.L.L. - VALDEZ HOUSE
FACILITY NUMBER: 405802280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2024
Section Cited
CCR
87705(b)(1-2)

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(b) ...Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:(1)Procedures for notifying...(2)Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic...This requirement has not been met as evidenced by:
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Licensee agreed to provide CCL with a addendum to the plan of operation adding a dementia program plan, if the program plan is not approved by CCL the facility will serve residents with Dementia a 60-day eviciton notice for relocation by TCRC.
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Based on record review the Licensee did not comply with the regulation above the facility does not have a plan of operation approved for dementia which poses an immediate 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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
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