<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602949
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:14:40 PM

Document Has Been Signed on 12/06/2023 04:14 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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: 4CENSUS: 2DATE:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator / Cecile Recto
Staff / Francis Gonzalez		TIME COMPLETED:
04:30 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
Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced Annual Required visit and inspection of the facility. LPA met with staff, Francis Gonzalez and shortly after met with Administrator Cecile Recto and explained the reason for the visit.

At 9:45a.m., with the assistance of Administrator, LPA took a tour of the physical plant for compliance with safety, maintenance, and operational requirements. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

The facility is located in a residential neighborhood. Required postings were observed in the entry area. The smoke alarms are hardwired and interconnected. The fire extinguisher is located in the kitchen area with purchased date of 03/17/2022. On 12/06/2023 Administrator purchased a new fire extinguisher and carbon monoxide detector. First aid kit is fully stocked with a manual. The facility is a single story home which consists of the following:
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 and cleaning supplies were stored in a locked cabinet underneath the sink.
Bedrooms: There were four (4) bedrooms designated for residents use. All residents bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting.
Bathrooms: There are two (2) bathrooms total one (1) designated for resident’s use one (1) designated for staff use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 110 degrees Fahrenheit.
Common Areas: These included the living room and dining area. The common areas were properly furnished.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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 12/06/2023 04:14 PM - It Cannot Be Edited


Created By: Antonia Alvizar On 12/06/2023 at 03:21 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY BOARD AND CARE
FACILITY NUMBER: 198602949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in one or more carbon monoxide detectors which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2023
Plan of Correction
1
2
3
4
Administrator has purchased a new Carbon Monoxide detector. POC has been cleared during today visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Naira Margaryan
LICENSING EVALUATOR NAME:Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY BOARD AND CARE
FACILITY NUMBER: 198602949
VISIT DATE: 12/06/2023
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
26
27
28
29
30
31
32
Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards. The laundry area is located on the side of the the facility. Cleaning supplies, detergents, toxic chemicals and extra hygiene supplies are locked in the garage.
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.
Staff Interview: LPA conducted staff interview.
Resident Interview: LPA attempt to conduct resident interview however residents were not available at the time of this visit.
Medications: Medical logs are available however staff do not provide medication to current residents because they are not prescribed any medication by their primary physician.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies observed cited on LIC809-D during the visit.

Exit Interview Conducted / A Copy of the Report was provided to Administrator Ms. Recto.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3