197610664-12-16-2024-31-AS-LNCA-DC27VT-20241216210028

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610664
Report Date: 12/16/2024
Date Signed: 12/16/2024 09:00:40 PM

Document Has Been Signed on 12/16/2024 09:00 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VALLEY MANOR		FACILITY NUMBER:	197610664
ADMINISTRATOR/ DIRECTOR:	KNIGHT-GLASS, NICOLE		FACILITY TYPE:	735
ADDRESS:	10222 GERALD AVE		TELEPHONE:	(909) 419-9907
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 0	DATE:	12/16/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:48 AM
MET WITH:	Nicole Knight-Glass- administrator		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

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At 9:48 AM Licensing Program Analysts (LPA), Leslie Ngo-Castaneda conducted an announced pre-licensing visit to the above facility and met with administrator Nicole Knight-Glass.

Fire Clearance was approved on 9/23/2024 for a maximum capacity of four (4) non-ambulatory residents.

The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of team touring the physical plant inside and outside and observed the following:

KITCHEN: The kitchen is equipped with a refrigerator, microwave oven and sink. At 10 AM, LPA observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of four (4). All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

FIRE EXTINGUISHER was last purchased on 8/22/2024 is located in between in between the kitchen and the dining table. First-aid is complete and new.

BEDROOMS: There are four (4) bedrooms designated for client use. All bedrooms are furnished with beds, dresser and required bedding and linen. Extra linen is available in the hallway cabinet. The bedrooms have sufficient closet space and have sufficient lighting. Facility will have awake staff. Bedroom #1, bedroom #2, bedroom #3, and bedroom #4 are private bedroom located by the hallway.

Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY MANOR	FACILITY NUMBER: 197610664
	VISIT DATE: 12/16/2024

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BATHROOMS: At 10:10 AM the LPA observed two (2) bathrooms are clean and in good repair. Properly supplied with toilet papers, soap, and paper towels. The hot water temperature measured between 117.1°F. observed appropriate grab bar and had non-skid mat. Bathroom #1 is located in the hallway in between bedroom #2 and bedroom #3. Bathroom #2 is located by the entrance of the facility. Hot water for bathroom #2 measured at 116.8°F.

COMMON AREAS: The facility maintains a comfortable temperature at 70°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Office is located by the entrance, by the living room.

MEDICATION: The medications will be kept in the kitchen cabinet and the team observed the cabinet kept locked and inaccessible to residents in care.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 10:35 AM they were tested and observed to be operational.

SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. The backyard is fenced. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There is no swimming pool or bodies of water in the backyard. The driveway, passageway and entrance to the home was clear of obstructions.

NO GARAGE – there is only street parking. In addition, LPA observed laundry room is located at beside the kitchen. The washer/dryer appear to be in good condition. Laundry supplies are kept lock and inaccessible when not in use with supervision.

Component III was conducted with the administrator and licensee. Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved. Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

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