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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850226
Report Date: 02/17/2022
Date Signed: 02/17/2022 01:43:06 PM

Document Has Been Signed on 02/17/2022 01:43 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:VALLEY CONNECTIONS-BALTARFACILITY NUMBER:
195850226
ADMINISTRATOR:MORTEL, PAULINEFACILITY TYPE:
735
ADDRESS:17138 BALTAR STTELEPHONE:
(818) 223-7299
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 4CENSUS: 0DATE:
02/17/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Pauline Mortel - Administrator TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted a Pre-licensing visit to the above facility. LPA met with Administrator Pauline Mortel and explained the reason for the visit. This pre-licensing is for a change of ownership. The home is currently operating as Fairhaven Homes Baltar Lic # 197609541. This home is licensed to serve (4) ambulatory clients with intellectual disabilities at Level II which North Los Angeles County Regional Center is the vendor. LPA met with Pauline Mortel - Administrator and explained the purpose of the visit.
At approximately 10:30am LPA conducted physical plant along with Administrator. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. Smoke detectors and Carbon Monoxide detectors appeared to function properly during time of visit.
Facility is a single-story residence and consists of a total of three (3) bedrooms and two (2) bathrooms designated for clients use. (1) bedroom is designated for staff use at this time. Fire clearance was approved for (4) ambulatory residents. Fire extinguishers were observed to be fully charged and purchased this May 2021. During physical plant tour LPA observed the required postings throughout the facility.

Kitchen: The kitchen appeared to be clean at this time and the appliances and fixtures functional during the time of visit. LPs observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are to be stored in a locked cabinet above the washer and dryer in the laundry area right next to the kitchen. No Cleaning supplies and toxins were observed in this area at this tie. To the right of the kitchen was the office area and dining room. Dining furniture in kitchen and dining room area appeared to be clean and sufficient at this time.

Bedrooms: The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a sufficient supply of linen and personal hygiene supplies in the hallway closet right outside of Clients' room #2.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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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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: VALLEY CONNECTIONS-BALTAR
FACILITY NUMBER: 195850226
VISIT DATE: 02/17/2022
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Continued from 809

Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom between between 109 - 110 degrees Fahrenheit.

Common Areas: These included the living room, dining area and office area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Planned activities and games were stored in each clients bedroom specific to the type of activity they enjoyed doing. Dining room furniture appeared to be relatively clean and functional at this time. Medications were observed stored in locked cabinents in the office area. Client files were observed locked in cabinets in this area as well. LPA observed (3) first aid kits properly supplied including a first aid manual.

Outdoor Area: There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. There are no bodies of water on the premises. Garage was accessible from the exterior. LPA observed a sufficient amount of PPE at this time. The garage mainly stored linen, some furniture pieces, and medical supplies. LPA observed a storage unit located in the far right corner of the property, inaccessible to clients in care. LPA observed storage unit to be filled with personal belongings at this time.

Record Review: LPA reviewed files for residents and staff that are regularly scheduled at the facility. All client files included admission agreements, medical assessments, appraisals, consent forms, and physician orders for medications. All staff had the sufficient training documentation, criminal record clearance and are associated to this facility. Staff schedule appeared sufficient to meet the needs of the clients at this time.

Comp III was completed in conjunction with the visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure. Licensee agreed to follow up with LPA to follow up on their capacity status once it has been changed. An exit interview was conducted with Administrator, and a hard copy was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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