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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602949
Report Date: 07/13/2022
Date Signed: 07/13/2022 04:33:42 PM

Document Has Been Signed on 07/13/2022 04:33 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VALLEY BOARD AND CAREFACILITY NUMBER:
198602949
ADMINISTRATOR:RECTO CECILEFACILITY TYPE:
735
ADDRESS:2220 N LAMER STREETTELEPHONE:
(818) 263-4222
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 1DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Cecile Recto,AdministratorTIME COMPLETED:
04:41 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1-year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Cecile Recto, LPA explained the purpose of the visit. This facility is vendorized through Frank D. Lanterman Regional Center. This is a single story home/facility that consist of: seven (7) bedrooms, three (3) bathrooms, living room, kitchen with dining area, office (in garage), laundry room, and outside covered area with chairs. The last fire drill was completed on February 1, 2022 Administrator certificate expires 06/25/2023

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility has no designated isolation room as clients have privates rooms where they can isolate.
· Five (5) resident rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· All client rooms were equipped with alcohol-based hand sanitizer
· Zero (0) centrally stored client medication records were reviewed as only client does not take medication.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.

Deficiencies cited please see 809D for details
Exit interview was conducted with Administrator Cecile Recto. A copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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 3
Document Has Been Signed on 07/13/2022 04:33 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/13/2022 at 03:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VALLEY BOARD AND CARE
FACILITY NUMBER: 198602949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. 2 spray cans of raid were left under bathroom sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2022
Plan of Correction
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Licensee wll lock up 2 spray cans of RAID.

****Licensee locked up the 2 spray cans of Raid during visit, no further action is required***
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Water in the facility measured 124.4 to 128.5 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2022
Plan of Correction
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Licensee adjusted the water temperture during visit and was measured at 108.6 which is within range.

****NO FURTHER ACTION IS REQUIRED***
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/13/2022 04:33 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/13/2022 at 03:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VALLEY BOARD AND CARE
FACILITY NUMBER: 198602949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Used plastic water pipe, 2x4 beams, and planters were scattered in the front and back yard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2022
Plan of Correction
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Licensee wii removed all the debris in front and back yard and send photo as proof to LPA by POC date.

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


LIC809 (FAS) - (06/04)
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