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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222733
Report Date: 10/22/2024
Date Signed: 10/31/2024 10:51:16 AM

Document Has Been Signed on 10/31/2024 10:51 AM - 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VALLEY VILLAGE ADULT DEVELOPMENT CENTERFACILITY NUMBER:
191222733
ADMINISTRATOR/
DIRECTOR:		THOMAS, DONNAFACILITY TYPE:
775
ADDRESS:20830/20834 SHERMAN WAYTELEPHONE:
(818) 587-9455
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY: 129CENSUS: 95DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Sousan Ayyad- administratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff supervisor Kenneth Aguilar and advised for the purpose of the visit. LPA met with Program director Sousan Ayyad who is the administrator and Michael Florita who is the behavioral director.

At 9:20 am, with the assistance of the administrator and behavioral director, LPA took a tour of the physical plant. Required postings were observed in the office area. There is a carbon monoxide alarm installed at the facility. Fire extinguisher located within the facility were in the kitchen and the hallways, where the charge date is 6/27/2024. During the visit the facility is at 74 degrees Fahrenheit. Facility is licensed to serve adult individuals in less than 24 hour care.

Physical Plant: The facility is consisted of two (2) buildings, the larger building is a two-story 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. 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.

Kitchen: LPA toured all the rooms in the large building. The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA observed that all cleaning supplies, knives and sharps were locked in the kitchen cabinet and inaccessible to the clients. Frozen foods are wrap, dated, and stored properly as well. The laundry room is used for cleaning attendees clothing when soiled and staff aprons/ uniform, detergents and other laundry items were locked and all items were inaccessible to the clients. (continued to LIC 809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733
VISIT DATE: 10/22/2024
NARRATIVE
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The kitchen is clean, there are three (3) 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.

The bathrooms and changing rooms The bathrooms designated for attendees to use. Bathroom in the main building is located close to the entrance where attendees can used and is separated from males and females. Common bathroom hot water temperature was measured at 110.1 degrees Fahrenheit. Cleaning supplies are being stored in a locked cabinet in the maintenance room. Bathrooms 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 110.1°F to 116.1° and within the required range.

The outside area: Facility provides a patio with furniture, with a gardening. Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.

Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current IPP’s and liability insurance a copy was handed to LPA. Planned activities are offered. Some attendees does not have admission agreement (AD), physician report, TB test, and consent forms (CF) deficiency will be issued in LIC 809-D.

Continue to LIC 809-C.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 10/31/2024 10:51 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/22/2024 at 12:56 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 VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(b)(1)
Admission Agreements
(b) Admission agreements must specify the following: (1) Basic services;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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2
3
4
Administrator needs to make sure that admission agreement is signed.
Type B
Section Cited
CCR
82068(b)(2)
Admission Agreements
(b) Admission agreements must specify the following: (2) Available optional services;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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2
3
4
Administrator needs to make sure that admission agreement is signed.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 10/31/2024 10:51 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/22/2024 at 12:56 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 VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(b)(3)
Admission Agreements
(b) Admission agreements must specify the following: (3) Payment provisions, including the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to make sure that admission agreement is signed.
Type B
Section Cited
CCR
82068(b)(3)(A)
Admission Agreements
(b) Admission agreements must specify the following: (3) Payment provisions, including the following: (A) Basic rate;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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2
3
4
Administrator needs to make sure that admission agreement is signed completely.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 10/31/2024 10:51 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/22/2024 at 12:56 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 VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(b)(3)(B)
Admission Agreements
(b) Admission agreements must specify the following: (3) Payment provisions, including the following: (B) Optional services rates;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to make sure that admission agreement is signed.
Type B
Section Cited
CCR
82068(b)(3)(C)
Admission Agreements
(b) Admission agreements must specify the following: (3) Payment provisions, including the following: (C) Payor;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to make sure that admission agreement is signed.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 10/31/2024 10:51 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/22/2024 at 12:56 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 VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(b)(3)(D)
Admission Agreements
(b) Admission agreements must specify the following: (3) Payment provisions, including the following: (D) Due date; and

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to make sure that admission agreement is signed.
Type B
Section Cited
CCR
82068(b)(3)(E)
Admission Agreements
(b) Admission agreements must specify the following: (3) Payment provisions, including the following: (E) Frequency of payment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to make sure that admission agreement is signed.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 6 of 13
Document Has Been Signed on 10/31/2024 10:51 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/22/2024 at 12:56 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 VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(b)(4)
Admission Agreements
(b) Admission agreements must specify the following: (4) Modification conditions, including requirement for provision of at least 30 calendar days prior written notice to the client or his/her
authorized representative of any basic rate change.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to make sure that admission agreement is signed.
Type B
Section Cited
CCR
82068(b)(5)
Admission Agreements
(b) Admission agreements must specify the following: (5) Refund conditions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to make sure that admission agreement is signed.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 7 of 13
Document Has Been Signed on 10/31/2024 10:51 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/22/2024 at 12:56 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 VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(b)(6)
Admission Agreements
(b) Admission agreements must specify the following: (6) Right of the licensing agency to perform the duties authorized in Sections 82044(b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to make sure that admission agreement is signed.
Type B
Section Cited
CCR
82068(b)(7)
Admission Agreements
(b) Admission agreements must specify the following: (7) Conditions under which the agreement may be terminated.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to make sure that admission agreement is signed.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 8 of 13
Document Has Been Signed on 10/31/2024 10:51 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/22/2024 at 12:56 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 VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(b)
Needs and Services Plan
(b) If the client is to be admitted and has no restricted health condition(s) as specified in Section 82092, then, no later than 30 days after admission, the licensee shall complete a written Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 record review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to have physician report when onboarding a new attendee.
Type B
Section Cited
CCR
82068.2(f)(1)(C)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include: (1) The client's desires and background and formal supports, obtained from the client's family or his/her authorized representative, if any, regarding the following: (C) Mental and emotional functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 record review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to have physician report when onboarding a new attendee.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 9 of 13
Document Has Been Signed on 10/31/2024 10:51 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/22/2024 at 12:56 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 VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(f)(2)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include: (2) A description of limitation of activities of daily living skills.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 record review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to have physician report when onboarding a new attendee.
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 record review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to have physician report when onboarding a new attendee.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 10 of 13
Document Has Been Signed on 10/31/2024 10:51 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/22/2024 at 12:56 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 VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 record review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to have physician report with TB test when onboarding a new attendee.
Type B
Section Cited
CCR
82070(b)(8)
Client Records
(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 82069(b).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 record review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Administrator needs to havea complete physician report with ambulatory status when onboarding a new attendee.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 11 of 13
Document Has Been Signed on 10/31/2024 10:51 AM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/22/2024 at 12:56 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 VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82070(b)(11)
Client Records
(b) Each record must contain information including, but not limited to, the following: (11) Restricted health condition care plan, if required for the client by Section 82092.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 record review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
1
2
3
4
Administrator needs to have physician report when onboarding a new attendee.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
Page: 12 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY VILLAGE ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 191222733
VISIT DATE: 10/22/2024
NARRATIVE
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Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office spaces are located along the hallways of the program center. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.

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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC809 (FAS) - (06/04)
Page: 13 of 13