197608982-1-17-2025-29-AS-EMOY-DCZU3G-20250117141330

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608982
Report Date: 01/17/2025
Date Signed: 01/17/2025 02:13:58 PM

Document Has Been Signed on 01/17/2025 02:13 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:	WALNUT GARDEN VALLEY VILLAGE		FACILITY NUMBER:	197608982
ADMINISTRATOR/ DIRECTOR:	BUDNERO, MAIA DR		FACILITY TYPE:	740
ADDRESS:	12823 COLLINS STREET		TELEPHONE:	(818) 358-2033
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Izhak Illouz - Licensee Representative / Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:20 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 Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:30 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator arrived shortly thereafter. The LPA met with Izhak Illouz –Licensee Representative / Administrator and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPA inspected the kitchen/food service area at 9:42 a.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. Chemical storage is kept locked under the sink. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 115.1 degrees Fahrenheit at 9:43 a.m. LPA observed an adequate amount of emergency food located in one of the kitchen cabinets adjacent to the refrigerator and in the garage. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 10:09 a.m., hardwire combination of smoke / carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed and fully charged on 1/03/2025. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 01/06/2025 and are conducted quarterly. Activities were observed in the common areas. A non-functional fireplace was noted in the living room covered by a bookshelf. Adjacent to the kitchen is a laundry room / area with a washer and dryer. Laundry detergent was observed locked in the garage. A small storage room containing extra mobility supplies and oxygen was noted at the entrance way adjacent to the living room. The facility has a working telephone on premises. Auditory alarms on all doors were functional at the time of the visit. Entry/exits were free of obstruction. Report Continued on LIC 809C...

Kasandra Lopez	TELEPHONE: (818) 596-4343
Erica Mosley	TELEPHONE: (747) 230-3909
	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT GARDEN VALLEY VILLAGE	FACILITY NUMBER: 197608982
	VISIT DATE: 01/17/2025

NARRATIVE

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Report Continued from LIC 809...
RESTROOMS: There are four (4) restrooms. Three (3) are designated for resident use and one (1) is designated as a staff/guest restroom; however, can be used by residents in an emergency. Resident restrooms were observed to be equipped with slip resistant surfaces. Grab bars were observed in the bathrooms. The restrooms were sufficiently stocked with supplies and paper towels. The water temperature was measured in all resident restrooms from 9:56 a.m. – 10:05 a.m. and ranged between 115.2-115.3 degrees Fahrenheit all within the required range.

BEDROOMS: There are six (6) total bedrooms in the facility; five (5) bedrooms are designated as private resident rooms and one (1) staff room. The staff room remains locked at all times. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #3 and #4 have a direct exit to the exterior. Bedroom #4 and #5 have a Jack and Jill bathroom.

GARAGE/BACKYARD: The garage is maintained locked at all times. LPA observed an adequate amount of emergency food and water. LPA observed two (2) extra refrigerators with food that was checked for proper labels and expiration dates. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit.

RECORDS: Record review began at approx. 10:15 am. Resident Records began at 10:15 a.m. Five (5) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Personnel Records were reviewed beginning at 10:57 a.m. Four (4) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

MEDICATIONS: Medications review began at approximately 11:40 a.m. The medications are in a locked cabinet in the kitchen. Medications for five (5) residents were reviewed. Medications reviewed including PRNs were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. Medications were labeled, stored, and locked inaccessible to residents. Medications were checked for expiration dates. PRNs have physicians order on file. No medication errors observed at this time. Report Continued on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT GARDEN VALLEY VILLAGE	FACILITY NUMBER: 197608982
	VISIT DATE: 01/17/2025

NARRATIVE

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Report Continued from LIC 809C...

INTERVIEWS: Two (2) staff interviews and two (2) resident interviews were conducted from 11:25 a.m. – 11:40 a.m. during the inspection. Staff interviews revealed that staff are knowledgeable in resident rights, different forms of abuse and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit.

LPA obtained the following documents LIC 500 - Personnel Report, LIC 9020 - Resident Roster, and current liability insurance.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report reviewed and provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

LIC809 (FAS) - (06/04)

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