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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602949
Report Date: 01/03/2023
Date Signed: 01/03/2023 04:48:25 PM

Document Has Been Signed on 01/03/2023 04:48 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
Lookup Error,
, CA
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: 2DATE:
01/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Cecile RectoTIME COMPLETED:
04:50 PM
NARRATIVE
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LPA Tihesha Smith met with Cecile Recto for an investigative visit and during the course of the investigation citations not related to the complaint were observed to be in deficiency.

A tour of the physical plant was conducted, and the following was noted:

Living cluttered with empty 5-gallon water bottles, various equipment and discarded furniture items waiting for removal. Two (2) bedrooms located in front of home designated as residents’ rooms are currently being used as staff rooms were observed to be unsanitary, cluttered, and in an unhabitable condition.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit Interview Conducted / Citations issued/Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2023
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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Document Has Been Signed on 01/03/2023 04:48 PM - It Cannot Be Edited


Created By: Tihesha Smith On 01/03/2023 at 03:52 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
,
, CA

FACILITY NAME: VALLEY BOARD AND CARE
FACILITY NUMBER: 198602949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2023
Section Cited
CCR
80087

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by:
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Administrator states having Veterans service pick up furniture items and will remove other equipment and bottles from livingroom and will send proof of correction.

POC date:01/24/2023
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Based on observation licensee failed to ensure facility sanitary and in good repair at all time which poses a potential health and safety risk to residents in care.
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Type B
01/24/2023
Section Cited
CCR80010

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(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.
This requirement is not met as evidenced by:
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Administrator will submit required documents (LIC 200/ Facility Sketch) to change capacity for facility to LPA by due date.

POC date: 01/24/2023
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Based on interview and observation licensee failed to submit required documentation to change facility capacity.
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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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2023


LIC809 (FAS) - (06/04)
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