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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609360
Report Date: 11/04/2022
Date Signed: 11/04/2022 03:21:48 PM

Document Has Been Signed on 11/04/2022 03:21 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:VALLEYHEART CARE HOMEFACILITY NUMBER:
197609360
ADMINISTRATOR:FENIQUITO, MICHELLEFACILITY TYPE:
735
ADDRESS:22346 PHILIPRIMM STTELEPHONE:
(747) 242-1588
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 4CENSUS: 4DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Michelle FeniquitoTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced to conduct a required annual visit. The LPA met with the Licensee/Administrator Michelle Feniquito and explained the reason for the visit. Upon arrival, the Licensee notified the LPA that three (3) out of four (4) clients were not in the facility at the time of the visit as one (1) was working, one (1) was at at day program and one (1) was out to lunch. The LPA toured the facility to ensure there are no health and safety hazards and to ensure regulatory compliance.

KITCHEN: Knives and chemicals are locked inaccessible. Appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The client rooms were furnished appropriately; beds had with clean linens and rooms had sufficient lighting. RESTROOMS: Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 2:25 p.m. water temperature measured at 105.0 degrees F, which is within the required range of 105-120 degrees F. Restrooms were fully stocked. Hand-washing signs were observed. COMMON SPACES: Fire extinguisher was observed to be full and last serviced on 6/9/2022. Fire alarms and carbon monoxide devices were observed, tested and functional at the time of the visit at approximately 2:50 p.m. The backyard had furniture and a covered area for resident use. The side gate door was self-latching. There were no bodies of water noted on on the property at the time of the visit. The property shares a backyard wall with a new 2 story unit that has a separate address and is only accessible from the perimeter of the property. This addition does not have any residents at this time. GARAGE: Washer and dryer are located in the garage with additional cleaning supplies and personal protective equipment. Garage was locked at the time of the visit. No cleaning supplies were observed to be accessible.

Continued on LIC 809-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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: VALLEYHEART CARE HOME
FACILITY NUMBER: 197609360
VISIT DATE: 11/04/2022
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INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry. Infection Control signs were observed throughout the facility. Facility has a sufficient supply of PPE. The facility’s cleaning protocol is sufficient. There was record of staff and resident vaccinations. The LPA discussed changes around testing, visitation, and vaccine requirements. The facility managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The facility's procedures as it pertains to infection control are adequate.

There were no immediate health and safety hazards observed during today's visit. Exit interview conducted and a copy of this report was emailed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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