197608982-12-21-2022-29-AS-AASO-CMC2K3-20221221162717

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608982
Report Date: 12/21/2022
Date Signed: 12/21/2022 04:32:28 PM

Document Has Been Signed on 12/21/2022 04:32 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:	WALNUT GARDEN VALLEY VILLAGE		FACILITY NUMBER:	197608982
ADMINISTRATOR:	BUDNERO, MAIA DR		FACILITY TYPE:	740
ADDRESS:	12823 COLLINS STREET		TELEPHONE:	(818) 358-2033
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 6	DATE:	12/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:39 AM
MET WITH:	Izhak Illouz		TIME COMPLETED:	11:50 AM

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) Angel Ascencio arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. LPA Ascencio met with staff member at 10:40 a.m. and explained the reason for the visit. Administrator Izhak Illouz arrived at the facility shortly thereafter. LPA Ascencio toured the physical plant areas inside and outside, with Administrator Izhak Illouz at 10:45 a.m. to ensure there are no health and safety hazards. BEDROOMS: There are (6) six bedrooms designated for resident use and (1) one bedroom designated for staff use. All resident bedrooms are private rooms. Bedroom #3 and Bedroom #4 have a direct exit to the exterior. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage. RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products. There are 4 total bathrooms at the home. Two (2) are private bathrooms in Room # 2 and 3. Room #1, 4, 5 and 6 use two (2) shared bathroom. Hot water temperature was tested throughout the home and was within normal ranges between 105.0 F and 120.0 F. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. Continued on LIC 809 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

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: WALNUT GARDEN VALLEY VILLAGE	FACILITY NUMBER: 197608982
	VISIT DATE: 12/21/2022

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The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system and carbon monoxide detector was tested and operated normally at the time of visit. Medications were observed to be locked in a cabinet in the kitchen and contained at least 30 days of worth of medication. The laundry room is located in a backroom by the kitchen. The backyard has a covered outdoor area equipped with furniture for resident use. There are no bodies of water noted. The garage was observed to be locked at the time of visit and contained emergency water, personal protective equipment (PPE) and laundry supplies.

KITCHEN: Kitchen knives are stored in a locked cabinet in the kitchen. The supply of dishes,
utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees
Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable
food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation
area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had
tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet under the kitchen sink. No flies or other vermin were observed.

INFECTION CONTROL: During today’s visit, LPA Ascencio spoke with Administrator regarding the
facility’s infection control practices at 11:20 a.m. There is 1 entry into the facility. Upon entry, the
facility has a central entry point for symptom screening. The LPA noted that the facility is allowing
visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal
Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The
facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation
room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of
COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

No citations were issued during today’s visit.

Exit interview conducted, and a copy of the report provided to Admin via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

LIC809 (FAS) - (06/04)

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