197607994-10-8-2021-31-AS-YAVN-C7LU8L-20211008152143

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607994
Report Date: 10/08/2021
Date Signed: 10/08/2021 03:24:14 PM

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VALENCIA MANOR HOMES #1		FACILITY NUMBER:	197607994
ADMINISTRATOR:	A.SERUMAL/T.STOKES		FACILITY TYPE:	740
ADDRESS:	23946 COLUMBIA COURT		TELEPHONE:	(661) 510-0615
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91355
CAPACITY:	6	CENSUS: 4	DATE:	10/08/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Staff Jocelyn Bumanglag		TIME COMPLETED:	03:45 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	An unannounced Plan of Correction (POC) visit was conducted on this day by Licensing Program Analysts (LPA's) Yelena Avetisyan and Angela Panushkina. he purpose of this visit is to follow up on the Plan of Corrections (POCs) that were issued during an annual visit made on 09/23/2021 by LPA Avetisyan. On Sep 29, 2021, at 10:29 AM LPA Avetisyan sent an email to aserumal@yahoo.com notifying the licensee that plan of corrections are still outstanding. At 3:32 pm a response email was sent from the licensee that he is working on the plan of corrections and will send it as soon as they are completed. As of today's visit the licensee has failed to submit plan of corrections to the Department. On 9/30/2021 LPA Avetisyan received notification from the Santa Clarita Fire Prevention that inspection was Completed at this facility earlier in the day and the following violations were observed: 1) ALL SMOKE ALARMS TO BE HARD WIRED INTERCONNECTED WITH BATTERY BACK UP. CBC 907.2.11.2.2 2) HALLWAY, GARAGE, BEDRIDDEN, AND INDIVIDUAL ROOMS WITHOUT A HALLWAY MUST HAVE FIRE RATED DOORS, BE SELF CLOSING, POSITIVE LATCHING 1-3/8” SOLID WOOD, PROVIDED WITH A GASKET TO BE SMOKE-TIGHT, SHALL NOT HAVE A LOCKING DEVICE AND SHALL BE RELEASED BY A DEVICE ACTUATED BY SMOKE ALARMS. CBC 425.8.3.2 3) 2 EXITS REQUIRED MINIMUM. ALL PATHS OF EGRESS KEPT CLEAR AT ALL TIMES. CBC 425.8.2.1 4) THIS FACILITY HAS NOT BEEN APPROVED FOR A BEDRIDDEN PATIENT, THE BEDRIDDEN PATIENT DOES NOT HAVE A MEANS OF EGRESS AND THE DOOR ON THE BEDRIDDEN PATIENTS ROOM IS NOT A FIRE RATED DOOR. 5) ALL DOORS TO BE LABELED AND CORRESPOND WITH NUMBER OF PATIENTS AND STATUS. DOORS THAT ARE NUMBERED IN THIS FACILITY HAVE BEEN ALTERED FROM ORI STD 850 FIRE SAFETY APPROVAL ON 7/8/2010. 6) RESIDENT BEDROOM #5 IS BEING USED FOR PATIENT, THE EGRESS IS BLOCKED AND THERE IS NO FIRE RATED DOOR ON THIS ROOM. THIS ROOM WAS NOT APPROVED ON STD 850 FIRE, SAFETY INSPECTION (7/8/2010) AS A PATIENT ROOM. 7) AWAITING VERIFICATION OF OCCUPANCY STATUS.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

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 9

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALENCIA MANOR HOMES #1	FACILITY NUMBER: 197607994
	VISIT DATE: 10/08/2021

NARRATIVE

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On 10/4/2021 LPA Avetisyan conducted review of the facility fire clearance and spoke with the LAFD Inspector to confirm the information retained by the department. Fire inspector confirmed that the original fire clearance granted for the facility is 3 ambulatory and 3 non-ambulatory. The licensee is required to complete all violations on the LAFD inspection report as well as the pending plan of correction for the deficiencies cited on 9/23/2021 by the Department immediately. .

The Licensing Report issued on 9/23/2021 Gave notice to the licensee that failure to correct the violations within a specified length of time would result in civil penalties being issued. During this visit the staff were notified that the civil penalties will continue to accrue until the violations are properly corrected:

87468.1(a)(2) (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on 9/23/2021 observation, the licensee did not comply with the section by not conducting routine symptom screening for staff and visitors. Additionally upon the LPA's arrival staff did not perform required symptom screening. During today's visit staff confirmed not receiving infection control training. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 9/24/2021 to 10/8/2021 totaling $1500.00

87411 (d)(5) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement is not met as evidenced by: Based on interview and record review conducted on 9/23/2021 and during todays visit the licensee did not comply with the section cited above in by not ensuring staff are fit tested for N95 masks as required and indicated in the licensees mitigation plan. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 9/25/2021 to 10/8/2021 totaling $1400.00.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

Page: 2 of 9

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALENCIA MANOR HOMES #1	FACILITY NUMBER: 197607994
	VISIT DATE: 10/08/2021

NARRATIVE

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87202 (a)(2) Fire Clearance All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance. This requirement was not met as evidenced by: Based on 09/23/2021 observation and interview the licensee did not comply with the cited section by retaining two bedridden resident (R2)(R3) without proper fire clearance. During this visit at 9:21 am LPA's observed staff transport R2 from bed to wheelchair with hoyer lift, while doing the transfer the staff had to reposition R2's foot to complete the task. After R2 was placed on the wheelchair at 9:27 am LPA's observed staff having to lift R2's arms to change clothing. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 9/24/2021 to 10/8/2021 totaling $1500.00. The $1500.00 penalty assessed is a continuation of the civil penalty issued on 9/23/2021 in the amount of $500.00 because this is a zero tolerance violation.

87355 (e)(1) Criminal Record Clearance. (e) ...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based on 9/23/2021 record review and interview, the licensee did not comply with the section cited above by not obtaining criminal record clearance for S2 prior to working at the facility The licensee did not notify the department how the deficiency was cleared. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 9/24/2021 to 10/8/2021 totaling $1500.00. The $1500.00 penalty assessed is a continuation of the civil penalty issued on 9/23/2021 in the amount of $500.00 because this is a zero tolerance violation. During this visit at 11:09 am S2 showed the LPA's documentation that she went to obtain her criminal record clearance on 9/28/2021. At 11:14 am LPA Avetisyan called the CCLD Woodland Hills Regional Office and confirmed that S2 has criminal record clearance however the clearance was not transferred to this facility. LPA's were provided LIC 9182 Criminal Background transfer request, photo ID and Criminal Record Statement for S2 and another staff who had criminal record clearance however the clearance was not transferred to this facility. Deficiency cleared during the visit.

Additional civil penalty was issued for Staff 3 (S3) who indicated she has been working at the facility since 2019, took time off for personal reasons and returned to work 9/24/2021.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

Page: 3 of 9

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALENCIA MANOR HOMES #1	FACILITY NUMBER: 197607994
	VISIT DATE: 10/08/2021

NARRATIVE

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87608 (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observations made on 9/23/2021 the licensee did not comply with the section cited above by utilizing full bedrails for R2 and R3 who are on hospice however licensee does not have hospice care plan which indicates the need for the rails which poses an immediate health, safety and personal rights risk to persons in care. Licensee did not submit the residents hospice care plan which indicates the need for the full rails. While conducting tour of the facility LPA's observed that R2 and R3 continue to utilize the full rails. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 9/24/2021 to 10/8/2021 totaling $1500.00.

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation made during the 9/23/2021 visit, the licensee did not comply with the section cited by not ensuring the fire extinguisher was serviced annually as required or a new fire extinguisher was purchased. At 9:10 am LPA's observed that the un-serviced fire extinguisher remained at the facility. Approximately 10:45 am staff Jorge Aquino replaced the fire extinguisher with a newly purchased one. Deficiency cleared during the visit. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 9/24/2021 to 10/7/2021 totaling $1400.00.

87465 (f)(1) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. This requirement is not met as evidenced by: Based on record review completed 9/23/2021, the licensee did not comply with the section cited by not following Emergency care requirements and completing/documenting the required information. As of this visit the licensee has not completed/documented the required information. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 10/1/2021 to 10/8/2021 totaling $800.00.

87465 (f)(2) Emergency care requirements shall include the following: (2) The name, address and telephone number of each emergency agency to be called in the event of an emergency, including but not limited to the fire department, crisis center or paramedical unit or medical resource, shall be posted in a location visible to both staff and residents. This requirement is not met as evidenced by: Based on observations made on 9/23/2021 the licensee did not comply with the section cited by not having the telephone number for each

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

Page: 4 of 9

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALENCIA MANOR HOMES #1	FACILITY NUMBER: 197607994
	VISIT DATE: 10/08/2021

NARRATIVE

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emergency personnel posted. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 10/1/2021 to 10/8/2021 totaling $800.00.

87307(a) Personal Accommodations and Services: Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by: Based on interview conducted with staff during the 9/23/2021 visit, the licensee did not comply with the section cited above by allowing staff to sleep in common area (living room). At 12:08 pm LPA's spoke with S1 who confirmed that S1 and S2 continuing to sleep in the living room. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 09/28/2021 to 10/8/2021 totaling $1100.00.

87633 (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based on 9/23/2021 visit record review, the licensee did not comply with the section cited above by not maintaining a hospice care plan for 2 out of 2 residents who are currently on hospice. During todays visit LPA's conducted review of records and did not observe hospice care plans obtained for the 2 residents. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 10/1/2021 to 10/8/2021 totaling $800.00.
87506 (a) Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on record reviews conducted on 9/23/2021 and during this visit the licensee did not comply with the section cited above by not maintaining complete facility files for 4 out of 4 residents. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 10/1/2021 to 10/8/2021 totaling $800.00.

87412(a)(11) 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) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Based on record review conducted on 9/23/2021, the licensee did not comply with the section cited above by not obtaining health screening and not having a file for S2. During this visit LPA's conducted review of staff files

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

Page: 5 of 9

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALENCIA MANOR HOMES #1	FACILITY NUMBER: 197607994
	VISIT DATE: 10/08/2021

NARRATIVE

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licensee did not complete file and did not obtain health screening for S2. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 10/1/2021 to 10/8/2021 totaling $800.00.

87632 (a)(1) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. The request shall include, but not be limited to the following: (1)Specification of the maximum number of terminally ill residents which the facility wants to have at any 1 time. This requirement is not met as evidenced by: Based on observations made and interviews conducted during the 9/23/2021 visit, the licensee did not comply with the section cited by retaining 2 hospice residents when the licensee has an approved hospice waiver for 1. During this visit LPA's confirmed that the licensee continues to retain 2 residents who are on hospice. Licensee did not submit a hospice waiver increase or hospice care exemption to the department. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 10/1/2021 to 10/8/2021 totaling $800.00.

87411 (c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:Based on record reviews conducted on 9/23/2021 and during todays visit, the licensee did not comply with the section cited above by not ensuring 2 out of 2 staff received first aid training For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 10/1/2021 to 10/8/2021 totaling $800.00.

1569.69 (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: This requirement is not met as evidenced by: Based on interview and record review conducted on 9/23/2021 and during this visit, the licensee did not comply with the section cited above by not ensuring proper medication training was provided to 2 out of 2 (S1, S2). As of todays visit the licensee has not scheduled training for staff. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 09/27/2021 to 10/8/2021 totaling $1200.00.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

Page: 6 of 9

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALENCIA MANOR HOMES #1	FACILITY NUMBER: 197607994
	VISIT DATE: 10/08/2021

NARRATIVE

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1569.696 (a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. This requirement is not met as evidenced by: Based on interview and record review conducted on 9/23/2021 and during today's visit, the licensee did not comply with the section cited above by not ensuring staff receive the required training. As of todays visit the licensee has not scheduled training for staff. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 09/27/2021 to 10/8/2021 totaling $1200.00.

1569.625 (b) Staff training; legislative findings; contents. (1) The department ...staff members ...who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. ...(2) training requirements shall also include an additional 20 hours annually. This requirement is not met as evidenced by: is requirement is not met as evidenced by: Based on interview and record review conducted on 9/23/2021 and during today's visit, the licensee did not comply with the section cited above by not ensuring staff receive the required training. As of todays visit the licensee has not scheduled training for staff. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 09/27/2021 to 10/8/2021 totaling $1200.00.

87405 (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: Based on observation, interview and record review conducted on 9/23/2021 and during today's visit, the licensee did not comply with the section cited by not having a currently certified administrator working at the facility. As of todays visit the licensee continues to not have certified administrator overseeing the operation of the facility. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 09/28/2021 to 10/8/2021 totaling $1100.00.

87705 (c)(5) Licensees who accept and retain residents with dementia shall be responsible for.... . Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: Based on record review conducted on 9/23/2021 and during today's visit the licensee did not comply with the section cited above by not ensuring a annual medical assessment is obtained for 4 out of 4 residents. During this visit LPA's observed current medical assessment for 1 out of 4 residents. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 09/28/2021 to 10/8/2021 totaling $1100.00.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

Page: 7 of 9

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALENCIA MANOR HOMES #1	FACILITY NUMBER: 197607994
	VISIT DATE: 10/08/2021

NARRATIVE

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87705 (f)(2) Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observations made and interviews conducted on 9/23/2021 and during today's visit the licensee did not comply with the section cited above by not ensuring medications are kept inaccessible to resident. As of today's visit staff confirmed that the lock on the medication cabinet has not been replace/repaired. For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 09/24/2021 to 10/8/2021 totaling $1500.00.

At approximately 10:30 am Staff Rie Santos and Jorge Aquino arrived to the facility. According to the staff they were contacted by the new owners of the facility as well as the current licensee to come to the facility. A discussion was held with staff throughout the visit about the seriousness of the pending plan of corrections, the immediate health and safety concerns, the civil penalties that are being issued due to the licensees (Old and New) failure to correct the deficiencies.

Approximately 1:00 pm LPA's requested for copy of the licensees liability insurance. Staff Santos contacted the current licensee via text, but did not provide any follow up information of copy of the liability insurance.

Exit interview conducted with Staff Jocelyn Bumanglag, Copy of report and civil penalties emailed to Aserumal@yahoo.com,rieulysses@gmail.com and goodshepardcareinc@gmail.com

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

Page: 8 of 9

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALENCIA MANOR HOMES #1	FACILITY NUMBER: 197607994
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/08/2021 Section Cited	1 2 3 4 5 6 7	(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c), This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on record review and interview the licensee did not comply with the section cited by not transferring the criminal record clearance for S3 to this facility prior to employment which poses a immediate health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 10/15/2021 Section Cited	1 2 3 4 5 6 7	Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests...This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on interview, the licensee did not comply with the section cited above by failing to obtain/maintain liability insurance as required which poses a potential health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14

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 Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

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