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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606826
Report Date: 02/23/2024
Date Signed: 02/23/2024 01:59:31 PM


Document Has Been Signed on 02/23/2024 01:59 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ANGELS OF THE VALLEY BOARD & CAREFACILITY NUMBER:
197606826
ADMINISTRATOR:YANA D. DIAZFACILITY TYPE:
740
ADDRESS:10700 RESEDA BLVD.TELEPHONE:
(818) 831-0058
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY:6CENSUS: 2DATE:
02/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Eric Macaisa- Assistant Administrator TIME COMPLETED:
02:05 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mariana Agban and Perchui Khurshudyan conducted an Annual Required visit and inspection of the facility. LPAs met with staff and explained the reason of the visit. At approximately 10:45 am, with the assistance of staff, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms were tested and function properly. The carbon monoxide detector was tested and functions properly.The fire extinguisher is located in the hallway. The purchase date Jan 3,2023.
Kitchen: The kitchen appliances and fixtures were functional. LPAs found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets.
Bedrooms: There were four (4) bedrooms designated for residents' use. Three (3) designated for residents' use and one (1) for staff. All three bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting.
Bathrooms: There are one (1) bathroom designated for residents' use. The bathroom was properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 105.3 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection.
Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area is located in the garage, which is inaccessible to residents.

Resident Files: LPAs conducted a file review of resident records to insure compliance of licensing forms.


Staff Files: LPAs also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.
Medications: Medication and Medication Records were reviewed. LPAs observed LEVOTHYROXINE medication is short by 1 bill for 2 out 2 residents. Assistant administrator couldn't explain the reason for the shortage. They were advised to use Medication Administration Record (MAR) to prevent any future issues with medications. Exit Interview conducted, citation issued and a Copy of the Report delivered
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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 02/23/2024 01:59 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANGELS OF THE VALLEY BOARD & CARE
FACILITY NUMBER: 197606826

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
87465(a)(4)


This requirement is not met as evidenced by:The licensee shall assist residents with self-administered medications as needed.
Deficient Practice Statement
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Based on the record review the licensee did not comply with the section cited above. LPAs observed LEVOTHYROXINE medication is short by 1 bill for 2 out 2 residents which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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The licensee agreed to follow the Medication Administration Record(MAR) for both residents and to provide a plan for staff to follow when residents miss a dose of medication for any reason. The plan should include immediate contact with the resident physician and CCLD. Plan to be submitted by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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