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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222733
Report Date: 10/06/2022
Date Signed: 10/06/2022 02:21:15 PM

Document Has Been Signed on 10/06/2022 02:21 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:VALLEY VILLAGE ADULT DEVELOPMENT CENTERFACILITY NUMBER:
191222733
ADMINISTRATOR:THOMAS, DONNAFACILITY TYPE:
775
ADDRESS:20830/20834 SHERMAN WAYTELEPHONE:
(818) 587-9455
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY: 129CENSUS: 59DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sousan Ayyad, Regina Arvizu-BranamTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted an unannounced one (1) year Required visit to this facility today. LPAs met with the Administrator Sousan Ayyad and Program Director, Regina Arvizu-Branam and explained the purpose of the visit.

The facility is consisted of two (2) buildings, the larger building is a two storey building with the first floor designated for the Day Program and the second floor is designated for corporate offices for all their programs. The ground floor has a total of six (6) activity rooms for clients and six (6) bathrooms. There is also a large dining room and kitchen area. There is a laundry room that is available for clients learning daily living activities. The smaller building has four (4) activity rooms and two (2) bathrooms. The program provides community based activities and classroom settings activities. The classroom activities include classes such as ceramics, communication, sensory & cognitive development, gross motor/fitness, sports, arts, music and daily living skills.

Physical plant: LPAs toured all the rooms in the large building. LPAs observed that all cleaning supplies, knives and sharps were locked in the kitchen cabinet and inaccessible to the clients. The laundry room used for daily living practice was open but the cabinet with detergents and other laundry items were locked and all items were inaccessible to the clients.



The Kitchen/Dining area was observed and the following was noted: The kitchen is clean, water temperature was tested at 118.8°F. There are two (2) refrigerators. One is designated for clients for their snacks and drinks and the other for staff use. The dining area have tables and chairs and was observed to be clean and sanitary during visit.

(continued to LIC 809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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 2
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: VALLEY VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733
VISIT DATE: 10/06/2022
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(continued from LIC 809)

The bathrooms and changing rooms were checked for cleanliness and proper operation, the following were noted: all client bathrooms and changing rooms were clean and water temperature was measured at 111.8°F to 118.0° and within the required range.

The outside area: Facility provides a patio with furniture, with a garden for clients to plant flowers and vegetables.

Fire extinguishers and smoke alarms are located throughout the facility. Fire extinguishers were observed to be fully charged and last checked on 07/07/22. There is a carbon monoxide alarm installed at the facility. All exits and passageways were checked and were clear of any obstruction.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC809 (FAS) - (06/04)
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