195850287-2-26-2024-29-AS-CYEE-D2U3S2-20240226172938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850287
Report Date: 02/26/2024
Date Signed: 02/26/2024 05:30:10 PM

Document Has Been Signed on 02/26/2024 05:30 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:	VALERIO RCFE		FACILITY NUMBER:	195850287
ADMINISTRATOR:	DONOVAN, KOHL		FACILITY TYPE:	740
ADDRESS:	14315 VALERIO ST		TELEPHONE:	(747) 264-0505
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 6	DATE:	02/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:	Francis Martir, Administrator		TIME COMPLETED:	05:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Lorna Montemayor, Staff. Francis Martir, Licensee was contacted via telephone and she arrived later to conduct the visit. The reason for today's visit was provided. The facility is a single storey building consisting of a kitchen, dining room, living room, 9 bedrooms of which 3 bedrooms located in the front are used for live-in staff, an attached garage and detached back house rented by part time staff/nurse. The facility is fire-cleared for 4 AMBULATORY, 1 NON-AMBULATORY and 1 BEDRIDDEN residents. Per copy of the STD850, Bedroom #1 is the designated room for 1 bedridden or 1 non-ambulatory use only and all the other rooms are for AMBULATORY use only. On today's visit LPA Yee reviewed 6 resident and 6 staff files. Also reviewed on today's visit were the following domains: Resident Records/Incident Reports and partially reviewed the Physical Plant and Environmental Safety domain. The following were observed on today's visit: The facility did not obtain a medical assessment for Resident #5 and the ambulatory status is unknown. Resident #1, who is diagnosed per Physician's Report as non-ambulatory was observed placed in Bedroom #5 which is fire cleared for ambulatory residents only. Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Immediate CIVIL PENALTIES were assessed. Any deficiencies not cited on today's visit will be addressed on return visit. Exit interview was conducted, APPEALS RIGHTS discussed and copy was given.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

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 02/26/2024 05:30 PM - It Cannot Be Edited

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: VALERIO RCFE	FACILITY NUMBER: 195850287
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87204(b)

Limitations -Capacity and Ambulatory Status

(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as Resident #1 who is determined to be non-ambulatory per physician, needs alot of assistance in transferring to a wheelchair and turning every 2 hours was observed in a hospital bed placed in bedroom #5, which poses an immediate health, safety or personal rights risk to persons in care. Immediate civil penalties were assessed.
	POC Due Date: 02/27/2024
	Plan of Correction
1 2 3 4	Licensee will provide a written statement as to how the facility will come back into complaince with the placement of Resident #1 in Bedroom #5, which is fire cleared for ambulatoy resident only, until the facility is able to obtain the appropriate fire clearance to retain an additional non-ambulatory resident at the facility.

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.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/26/2024 05:30 PM - It Cannot Be Edited

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: VALERIO RCFE	FACILITY NUMBER: 195850287
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 per review of Resident #5's file that there was no medical assessment(LIC602)Physician's Report obtained or maintained in Resident #5's file. It is unknown at this time what the resident's medical condition is or whether the resident has a contagious disease, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/04/2024
	Plan of Correction
1 2 3 4	The Licensee will ensure that the facility will obtain and maintain a medical assessment on file for residents in care Licensee will contact the doctor to obtain a copy of Resident #5 medical assessment and maintain in the resident's file by 3/4/24

Type B

Section Cited

CCR

87458(b)(5)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both. 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 per file review, Resident #5's file does not contain a copy of a medical assessment and it is unknown if the resident is ambulatory or non-ambulatory and if the resident is appropriately placed in the correct fire cleared room which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/04/2024
	Plan of Correction
1 2 3 4	The Licensee will contact Resident #5's physican to obtain a medical assessement that includes the medical determination whether the residenti is ambulatory, non-ambulatory or is bedridden for appropriate room placement by 3/4/24.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

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