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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802280
Report Date: 07/18/2025
Date Signed: 07/18/2025 04:20:34 PM

Document Has Been Signed on 07/18/2025 04:20 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:
07/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Kylan Reynoso, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon arrived at 10:00 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 a 30 day supply of PPE. PPE and infection Control Training is done initial upon hire and annually thereafter. 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 4 residents with 1 bedroom being shared. The facility employs 9 staff and 1 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 awning for shade. Laundry room is in the garage and has a working washer and dryer, kept locked with all laundry and cleaning supplies.

Operational Requirements: The Facility is operating in compliance with granted fire clearance. The facility is cleared for 4 non-ambulatory with a Hospice wavier granted for 4. The facility liability insurance expires 09/01/2025.
Continued 809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2025
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 43
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 43
Document Has Been Signed on 07/18/2025 04:20 PM - It Cannot Be Edited


Created By: Rachael De Leon On 07/18/2025 at 03:15 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: 07/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 3/4 staff did not have records on file at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Administrator agreed to get a staff files up to date and send in the health screeening with TB results for the staff missing in files.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
Page: 3 of 43
Document Has Been Signed on 07/18/2025 04:20 PM - It Cannot Be Edited


Created By: Rachael De Leon On 07/18/2025 at 03:15 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: 07/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 3/5 staff did not have CPR card on file at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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The facility is required to have a staff on each shift with CPR. Administrator agreed to get files up to date and CPR cards on file for 3/5 staff at the facility.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 3/5 files were not complete at the facility for staff and administrator which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Administrator agreed to get all staff records up to date and on file at the facility. Take a video of each file with contents and send to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
Page: 4 of 43
Document Has Been Signed on 07/18/2025 04:20 PM - It Cannot Be Edited


Created By: Rachael De Leon On 07/18/2025 at 03:15 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: 07/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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3
4
Based on record review, the licensee did not comply with the section cited above in 3/5 files reviewed did not have the required trianing in the files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Administrator agreed to get all files at the facility and updated with all required records/forms/trianing, take video of each file with contents and send to LPA.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in food was stored without wrapping or covers in the refrigerator which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Administrartor agreed to go through refrigerator and throw out any food not covered or marked accorndingly. Send LPA a photo of refrigerator cleaned out and everything stored properly.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
Page: 5 of 43
Document Has Been Signed on 07/18/2025 04:20 PM - It Cannot Be Edited


Created By: Rachael De Leon On 07/18/2025 at 03:15 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: 07/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 2/4 were missing signed admission agreement, pre placement appraisal or reapprisals were not present in the files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Administrator agreed to get all 4 files completed with all required forms and send LPA a video of all for 4 files with all forms present.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 4 files did not have preplacment appriosals and functional capabilites asseseements to determin adequate placements were done which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Admiistrator agreed to find all preplacment apprisal and functional capabitlies assessments and put in files at the faciltiy, send photograph of each file with these forms.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
Page: 6 of 43
Document Has Been Signed on 07/18/2025 04:20 PM - It Cannot Be Edited


Created By: Rachael De Leon On 07/18/2025 at 03:15 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: 07/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)(A)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 4/4 files did not have funcational capabilties assessments which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Administrator agreed to do functional capabilites assesments on 4 residents and put forms in the files send picture to LPA.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 1/4 residents did not have an update ANS or ISP on file at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Administrator agreed to send resident updated ISP/ANS to LPA and put in resident file.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
Page: 7 of 43
Document Has Been Signed on 07/18/2025 04:20 PM - It Cannot Be Edited


Created By: Rachael De Leon On 07/18/2025 at 03:15 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: 07/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in medical visits and recoes were not updated every 12 months which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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2
3
4
Administrator agreed to get update medical records in resident files for 2025. Take photograph and send to LPA.
Type B
Section Cited
HSC
1569.885(c)
Admission Agreements
(c) The admission agreement shall inform a resident of the right to contact the State Department of Social Services, the long-term care ombudsman, or both, regarding grievances against the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in the admission agreements do not have this information in them which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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3
4
Administrator agreed to make sure admission agreements met all requirements of regualtion and have CCL and LTCO grievance and complaint information for an RCFE. Send LPA a copy of the new admission agreements.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
Page: 8 of 43
Document Has Been Signed on 07/18/2025 04:20 PM - It Cannot Be Edited


Created By: Rachael De Leon On 07/18/2025 at 03:15 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: 07/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1/4 residents did not have an admission agreements on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
1
2
3
4
Admiistratror agreed to do find or do a new admisison agremeent with residents and put in residents file and send copy of AA to LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
Page: 9 of 43
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: 07/18/2025
NARRATIVE
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Staffing: The facility employes 9 staff and 1 Administrator. Staff records are kept confidential. Staff records were reviewed for 5 staff for fingerprint clearance and associations, personnel record or application, First Aid and CPR certificates and Health screening with TB results. 3/5 Staff had missing records or files.

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 2025. Some staff had training records but the records did not met the amount of hours or the required topics. The facility is using Relias online system for 2025 but did not have the records present for the staff at the facility. Administrator Certificate expires 12/03/2025.

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. The four files reviewed were lacking records and not complete at this time.

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.

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. The residents attend day programs during the day.

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. Foods need to be wrapped and stored with lids.

Continued 809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC809 (FAS) - (06/04)
Page: 42 of 43
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: 07/18/2025
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Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for all 4 residents. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR) and the Medication Administration record. all were up to date, legible and written as prescribed. LPA completed a full audit on four residents medication, all medications were in original containers, prescription labels were not altered, doctors orders were present and dispensing instructions were followed.

Disaster Preparedness: The current emergency disaster forms were posted. The fire extinguishers were charged and last inspected 12/18/2024. The smoke detectors and carbon monoxide detectors are present. The facility does conduct disaster drills at facility but records were not up to date for the last 4 quarters.

Residents with Special Health Needs: The facility has submitted a updated 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 currently have any residents on hospice and home health services.

Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC809 (FAS) - (06/04)
Page: 43 of 43