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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800867
Report Date: 01/07/2025
Date Signed: 01/07/2025 03:58:27 PM

Document Has Been Signed on 01/07/2025 03:58 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ARC-HERITAGE VALLEYFACILITY NUMBER:
565800867
ADMINISTRATOR/
DIRECTOR:		SONIA SALINASFACILITY TYPE:
775
ADDRESS:116 NORTH 10TH STREETTELEPHONE:
(805) 933-9029
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY: 90CENSUS: 37DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Katie GomezTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Esther Cortez arrived at the Adult Day Program (ADP) unannounced to conduct a required annual visit at 11:35 a.m. The LPA met with Administrator Kathleen “Katie” Gomez and explained the reason for the visit. The program currently operates from 8:00 a.m. to 3:00 p.m. The day program was staffed with 1:3 staff to consumer ratios.

Starting at 12:00 p.m., the LPA and the Administrator toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The smoke alarms and carbon monoxide detectors were tested throughout the tour and were operational. However, the LPA observed the medication room and the front two (2) offices without a smoke detector. Cleaning supplies are stored in a locked area.

Common Activity Space: Furnishings were observed to be in good condition. The facility has two large activity spaces, a dining room, and a craft room. The LPA observed the required postings throughout the facility as well as the monthly activity schedule. The program site appeared to be clean, safe, sanitary, and in good repair at this time. The LPA observed fire extinguishers throughout the facility, which were last serviced 06/12/2024.
Activities: Activities are both designed for individual and as a group. Activity supplies were observed in the large activity room.
Food Service: The kitchen area was clean and locked. Consumers bring their lunch and snacks. The facility has emergency food supplies and snacks available for consumers.
Restrooms: The three restrooms were observed to be clean and sanitary with a hand soap and paper towels. The hot water temperature in the restroom was tested at 12:10 p.m., 12:31 p.m. and 12:34 p.m. and they measured at 106.0, 107.4, and 109.8 degrees Fahrenheit.

Report will continue on LIC809-C, 2nd page.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARC-HERITAGE VALLEY
FACILITY NUMBER: 565800867
VISIT DATE: 01/07/2025
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Changing Room/Medication Room: The changing room had a supply of hygiene products, a bed with protective paper that is changed between clients and a hoyer lift if needed. This room is used as an isolation room if necessary, and is also where the medications are stored. The room is always locked

Medication Audit: A medication audit for three (3) clients was initiated at 12:47 p.m. and the


following was observed. The medications were stored in a locked cabinet inside a locked office and
inaccessible to the clients. All medications were properly documented on the centrally stored medication and destruction log (CSMDR).

Record Review: At 1:18 p.m. a review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention, and Insurance liability. The LPA obtained Client Roster, Staff Roster, and Staff schedule. The LPA reviewed five (5) of thirty-seven (37) client files and five (5) of eighteen (18) staff files. All resident and staff documents reviewed appeared complete and current.

Interviews: During today's visit, the LPA interviewed two (2) staff and two (2) consumers. No immediate concerns voiced at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted and copy of the report and appeal rights provided to Administrator.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/07/2025 03:58 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/07/2025 at 03:45 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARC-HERITAGE VALLEY
FACILITY NUMBER: 565800867

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82020
Fire Clearance
All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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 in three rooms that did not have a smoke detector which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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Upon observation, staff placed new smoke detectors in all three rooms.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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