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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802280
Report Date: 07/26/2024
Date Signed: 07/26/2024 04:51:17 PM

Document Has Been Signed on 07/26/2024 04:51 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: 3DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Kylan Reynoso, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) De Leon arrived at 11:30 am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Kylan Reynoso and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit:
Infection Control: The facility has submitted a current Infection Control Plan to CCL. The facility has EPA approved disinfectants spray and cleaners. The facility has trash cans/bins with covers. The facility has a 30 day supply of PPE. PPE and infection Control Training is done annually. All sinks have soap, paper towels, hand washing signs.
Physical Plant & Environment Safety: The facility is a 3 bedroom and 2 bathroom home currently occupying 3 residents and 8 staff, including one administrator. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The facility is fully fenced around the backyard with a self closing and latching gate. The facility has a patio with furniture and umbrella for shade. Laundry room has working washer and dryer.
Operational Requirements: The Facility is operating in compliance with fire clearance. The facility is cleared for 4 non-ambulatory with a Hospice wavier granted for 4. The facility liability insurance expires 09/01/2024.
Staffing: The facility employes 7 staff and 1 Administrator. Staff records are kept confidential. Staff records were reviewed for 5 staff. 3/5 Staff records reviewed had fingerprint clearance and associations, personnel record or application, First Aid and CPR certificates and Health screening with TB results. 7/8 staff had current first aid and cpr card verified. One staff will not work until it is renewed. 2/8 staff had current CPI cards.
Personnel Records & Training: The facility keeps confidential files for each staff member. The facility staff are not meeting the required hours and subjects for initial and annual training and are currently scheduled to take all required training's for 2024.



SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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 07/26/2024 04:51 PM - It Cannot Be Edited


Created By: Rachael De Leon On 07/26/2024 at 04:06 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: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, the facility did not have a working carbon monxicde detector which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2024
Plan of Correction
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Administrator agreed to install new carbon monoxide dectector and send LPA a photograph.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 in 8/8 staff were not meeting the intial or annual trianing requirements which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Administrator agreed to have all staff take the required initial or annual trianing and have all records at the facility for inspection. Provide an up to date LIC 500 and each staffs 40 intial or 20 annual trianing requirements completed and send proof to CCL.
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: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L. - VALDEZ HOUSE
FACILITY NUMBER: 405802280
VISIT DATE: 07/26/2024
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Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four Files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), Immunization records, TB results, Personal Rights, and Safeguard for personal property and valuables. Files are in compliance.
Resident Rights Information: All require postings were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, Nondiscrimination notice in addition to a CCL Complaint poster, and LTCO poster.
Planned Activities: The facility offers activities to all residents in care. Activities include books, magazines, newspapers, TV watching, daily walks, group discussions and communications and gestures, with games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors.
Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available in the garage.
Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for all 3 residents with the Centrally Stored Medication and Destruct Records (CSMDR) all were up to date, legible and written as prescribed. LPA completed a full audit on three residents medication, all medications were in original containers, prescription labels were not altered, doctors orders were present and dispensing instructions were followed and not medications were expired.
Disaster Preparedness: The current emergency disaster forms were posted. The facility 1 disaster drill for 2024, and 2 from 2023. and will add additional drills to their schedules. The fire extinguishers were charged and last inspected 12/2023. The smoke detectors are present. Facility is getting a new carbon monoxide detector.
Residents with Special Health Needs: The facility has submitted a update plan of operation to accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility does not have delayed egress. The facility does not have any residents with oxygen. The facility does not have hospice and home health currently visiting any residents in care.


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: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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