198600312-6-18-2025-31-AS-MCAA-DHRSF5-20250618134945

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600312
Report Date: 06/18/2025
Date Signed: 06/18/2025 01:49:55 PM

Document Has Been Signed on 06/18/2025 01:49 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	KOCH-VAGTHOL'S METABOLIC RESIDENTIAL CENTER		FACILITY NUMBER:	198600312
ADMINISTRATOR/ DIRECTOR:	CHAMU-NESTOR, FRANCISCA		FACILITY TYPE:	735
ADDRESS:	753 SOUTH MARIPOSA STREET		TELEPHONE:	(818) 843-2695
CITY:	BURBANK	STATE: CA	ZIP CODE:	91506
CAPACITY: 5		CENSUS: 5	DATE:	06/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:29 AM
MET WITH:	Emmeline Baldoza, Rodel Serrano		TIME VISIT/ INSPECTION COMPLETED:	02:00 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	An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Michael Cava. LPA met with staff, Emmeline Baldoza, and advised her of the annual. The administrator, Rodel Serrano, joined shortly after. This is a Lanterman Regional Center vendored facility Level IV-I Specialized. LPA conducted a physical plant tour inside and out at approximately 9:45am. The facility is a one story building. It has a fire clearance for five (5) non-ambulatory clients. The smoke alarms are hard wired. There are three functional carbon monoxide detectors throughout the facility. The fire-extinguisher is located in the kitchen. It was charged on October 23, 2024. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer, underneath the kitchen sink. Bedrooms: There are a total of seven (7) bedrooms in the home. Five (5) of the bedrooms are used for client use. One room is for live in staff, and the other room is staff lounge. The five bedroom designated for the client use are all private. These bedrooms were observed to be properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are three (3) bathrooms designated for residents' use. These bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 109 and 114 degrees.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Michael Cava
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: KOCH-VAGTHOL'S METABOLIC RESIDENTIAL CENTER	FACILITY NUMBER: 198600312
	VISIT DATE: 06/18/2025

NARRATIVE

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Common Areas: There are two living room areas, properly furnished with couches, recliners, tables and chairs. The dining room table is large enough to seat up to six (6) individuals. Living room and dining room furniture were in good repair. Floors were mopped and clean. Exits and passageways were clear.

Surrounding Grounds: There is an enclosed patio area with furniture appropriate for outdoor use. There are two locked storage rooms utilized for extra food and supplies. Administrator office is also located in the backyard. There are no bodes of water. Earthquake drill was last conducted on 04/22/25 and last fire drill conducted on April 12, 2025.

Laundry area: The laundry room is located in the hallway, between resident bathrooms. It is kept locked as detergents and cleaning supplies are maintained inside.

Staff Workstation/Office: Staff office is located by the front entry, where resident and staff files are kept.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medications are stored in a locked in a kitchen cabinet. Medication and Medication Records were reviewed for proper storage and documentation.

Garage: There is no garage, but a car port, located by the backyard.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Michael Cava
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC809 (FAS) - (06/04)

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