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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850226
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:23:10 PM

Document Has Been Signed on 03/19/2024 03:23 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
WOODLAND HILLS N.ASC, 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: 4DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Pablo MortelTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced at 8:45 a.m. to conduct a required annual. Upon arrival LPA met with Assistant Administrator Pablo Mortel and explained the reason for the visit. LPA spoke with Administrator Pauline Mortel over the phone, who stated she could not be present at the facility in the morning; however, she will be coming after noon. At 12:43 p.m. Administrator Pauline Mortel arrived at the facility.

At 9:12 a.m., a physical plant tour was conducted. Facility was approved for four (4) ambulatory clients only. Facility is vendorized by North Los Angeles County Regional Center (NLARC) as a Level II home. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. Smoke detectors and Carbon Monoxide detectors were checked at 9:56 a.m. and appeared to function properly during time of visit. Fire extinguishers were observed to be fully charged and purchased ­03/09/2024.

Facility is a single-story residence and consists of a total of three (3) bedrooms and two (2) bathrooms designated for clients use. “Room #2” is designated for staff use only, room has a bathroom inside which is for facility staff only.

Kitchen: The kitchen appeared to be clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility properly stored. Sharp objects are 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 time. Trash cans had tight fitting lids. At 9:29 a.m., LPA measured the water temperature, which measured at 119.2 degrees Fahrenheit. To the right of the kitchen was the office area and dining room. Dining furniture and dining room area appeared to be clean at this time.

Continued on LIC 9009-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY CONNECTIONS-BALTAR
FACILITY NUMBER: 195850226
VISIT DATE: 03/19/2024
NARRATIVE
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Continued from LIC 9099

Bedrooms: The resident bedrooms were properly furnished with a bed, nightstand, and sufficient lighting for each resident. All beds were stripped of all linens for scheduled laundry round and the airing of the mattress. However, assistant administrator stated that before all clients come back from activities rooms will have adequate linens such as sheets, pillowcases, and blankets. LPA observed a sufficient supply of linen and personal hygiene supplies in the hallway closet.

Bathrooms: LPA observed all bathrooms were clean, properly supplied with appropriate paper and hygiene products and had functional fixtures. The hot water was measured in each bathroom between 111.9 – 118.7 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. Dining room furniture appeared to be clean and functional at this time.

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 storage unit located in the far-right corner of the property, is locked and inaccessible to clients in care. LPA observed storage unit to store seasonal decoration and Administrator’s personal items. The facility is gated with accessibility through driveway entrance. LPA observed gate to be only opened manually at this time.

Medications were observed stored in locked cabinets 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 one (1) first aid manual. Assistant Administrator was provided with LIC 622 to keep record of all medication information need it by the Department.

Interviews: During today's visit, LPA was unable to interviewed clients, all 4 clients are at a day program.

Continued on LIC 9099-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY CONNECTIONS-BALTAR
FACILITY NUMBER: 195850226
VISIT DATE: 03/19/2024
NARRATIVE
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Continued from LIC 9099-C

LPA reviewed two (2) staff files for, but not limited to: fingerprint background clearance, health screening, TB test, and training records. One (1) out of two (2) staff files reviewed were in compliance with regulation. During today’s visit, LPA requested to review the files of the administrator but was unable due it being stored at a different location. LPA explained that all files should be accessible to Licensing to audit/review during normal business hours. LPA further explained that it is acceptable for the files to be stored in a central location however, whenever Licensing requests to review those files, it should be readily available and accessible. Furthermore, Administrator certificate for Pauline Mortel showed expired as of January 2024, according to Administrator renewal form and fees were mailed to Sacramento but have not been received as of today’s date.

During today’s visit, LPA also reviewed 4 client files. Three (3) out of four (4) client files were observed to have all required documents. During the file review, LPA observed Client #1 (C1) to have a prohibited health condition. LPA explained that the facility cannot retain a resident with a prohibited health condition. LPA and administrator discussed infection control practices and contacting C1’s Primary Care Physician (PCP). Administrator agreed to take all necessary precautions and obtain an updated Physician Report for C1.

Emergency disaster drills are not being conducted quarterly at the moment Administrator is doing them every six (6) months, with the last drill conducted on 09/09/2023. LPA explained that these Emergency drills needs to be completed and updated every 3 months, as required.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D)

Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/19/2024 03:23 PM - It Cannot Be Edited


Created By: Valeria Conway On 03/19/2024 at 02:43 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: VALLEY CONNECTIONS-BALTAR
FACILITY NUMBER: 195850226

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80091(a)(2)
Prohibited Health Conditions
(a) In adult CCFs clients who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained. (2) Active, communicable TB.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 4 clients had active TB test result which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2024
Plan of Correction
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Administrator agreed to follow all infection control guidelines and to provide a plan by POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 03/19/2024 03:23 PM - It Cannot Be Edited


Created By: Valeria Conway On 03/19/2024 at 02:43 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: VALLEY CONNECTIONS-BALTAR
FACILITY NUMBER: 195850226

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 2 staff files were not accessible to the Department which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Administrator agrees to provide all her personnel file by POC due date.
Type B
Section Cited
CCR
80066(a)(11)
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: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 2 staff files were not accessible to the Department which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Administrator agrees to provide all her personnel file by POC due date.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 03/19/2024 03:23 PM - It Cannot Be Edited


Created By: Valeria Conway On 03/19/2024 at 02:43 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: VALLEY CONNECTIONS-BALTAR
FACILITY NUMBER: 195850226

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)1
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: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as administrator certifiacte is expired which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Administrator agrees to provide receipt of submition of Administrator renewal form.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Administrator was unable to provide recent emergency drill which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Administrator agrees to complete a Fire or Earthqueake drill with clients and staff by the POC due date.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


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