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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609643
Report Date: 05/10/2024
Date Signed: 05/10/2024 02:27:58 PM


Document Has Been Signed on 05/10/2024 02:27 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:VALERIO CASTLE INCFACILITY NUMBER:
197609643
ADMINISTRATOR:HAKOBYAN, ANNAFACILITY TYPE:
740
ADDRESS:15360 VALERIO STTELEPHONE:
(310) 435-1445
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:4CENSUS: 4DATE:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Anna HakobyanTIME COMPLETED:
03:00 PM
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At 9:00 a.m. Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with staff. Administrator Anna Hakobyan arrived shortly after and explained the reason for the visit. The facility serves level 3 clients from North Los Angeles County Regional Center.

The facility is a single-story residence and has (2) private bedrooms and one (1) shared bedroom for resident use and one (1) bedroom designated for staff. At 9:35 a.m. 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. At the time of the visit, two (2) residents were attending day program and two (2) residents were observed at the facility. Residents were observed to be well-groomed and communicated no concerns to the LPA during the tour. The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. Fire extinguisher was observed fully charged and purchased in January 2024.

Bedrooms: All rooms are set up with beds, nightstands, 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 between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair.

Continued on LIC 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
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 4


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: VALERIO CASTLE INC
FACILITY NUMBER: 197609643
VISIT DATE: 05/10/2024
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Continued from LIC 809

Bathrooms: There is one (1) bathroom in the common area designated for resident use. Hot water temperature measured at 111.5 F degrees at the time of visit. The resident’s bathroom has a shower with non-skid materials and mats. The toilet and shower have grab bars. The bathroom nearest to the kitchen is designated as a staff restroom. The hot water temperature was tested in the staff bathroom and in the kitchen and was found to be within the range of 105*F and 120*F degrees. Bathroom located in master room is not in use, inside there are PPE supplies, emergency supplies, linen and extra towels. This room has a “For Employees Only” sign and it is locked at all times.

Kitchen: Knives and sharp objects are stored in the top drawer to the right of the sink. LPA observed it to be inaccessible to residents in care. Stove burners are rendered inaccessible to the residents these have a clear plastic cover to prevent residents from turning the stove on. 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 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 the garage inaccessible to residents in care. The first aid kit was observed in the kitchen, and it is complete and included a current version of a first aid manual. No flies or other vermin were observed.

Common areas: Including the dining and living room, these were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room and dining area. Night lights were maintained in hallways and passageways to non-private bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. LPA observed supply of extra bed and bath linens in a closet along the hallway. There is a functioning telephone on the premises. Administrator and facility license, LIC 500, Emergency Disaster Plan and more emergency telephone numbers are posted on a bulletin board in the entry way. The emergency exiting plans/sketch are posted throughout.

Continued on LIC 809-C

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
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: VALERIO CASTLE INC
FACILITY NUMBER: 197609643
VISIT DATE: 05/10/2024
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Continued from LIC 809-C

Medication: They are stored in the locked entry way closet. Medications are centrally stored in this area as well.. The emergency telephone numbers are posted on the closet’s door. Medications review began at 1:37 p.m. The medications are centrally stored and locked in a closet in the hallway. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

Laundry area: Located between the garage and the kitchen. Personal hygiene items (shampoos, soaps) were adequate and are stored in a cabinet above the washer and dryer.

Outdoor space: There is a covered patio area at the back of the house with table and chairs where residents can sit. At 09:12 a.m., LPA observed construction being done in the back yard. Per licensee Kano Darbinyan, an accessory dwelling unit (ADU) is being constructed. During today’s visit, LPA requested that the administrator keep the LPA updated with the progress of the construction and submit an updated facility sketch upon completion. Discussion was also held regarding staff prioritizing safety measures to ensure all residents are safe during the construction. Additionally, LPA also informed administrator that any individual that is living in the ADU should be fingerprinted and associated to the facility prior to residing. Moreover, LPA also reminded Administrator that facility shall provide sufficient space to accommodate outdoor activities. There are no bodies of water on the premises at the present time. Garage is attached to the home and was observed to be inaccessible to residents in care. LPA observed the garage locked and to store emergency food supplies, extra non-perishable foods, PPE, medical supplies and incontinent supplies.



Continued on LIC-809C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: VALERIO CASTLE INC
FACILITY NUMBER: 197609643
VISIT DATE: 05/10/2024
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Continued from LIC 809-C

Records review: At 11:30 a.m., LPA reviewed four (4) resident records for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were observed to be in order. LPA observed two (2) residents to have half (1/2) bed rails and one (1) resident requires a Hoyer lift to be transfer from bed to wheel chair. Four (4) personnel records were reviewed for staff, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. The last fire drill took place on 08/2023, LPA explained Administrator that an emergency drill is required every 3 months. Administrator will conduct a drill and send proof to LPA.

During today’s visit, the LPA obtained copies of the following: staff roster, resident roster, Emergency Disaster Plan, Surety Bond, and current liability insurance.

No deficiencies were cited at this time. Exit interview conducted. Signatures obtained. A copy of report was issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4