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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222733
Report Date: 12/05/2024
Date Signed: 12/05/2024 12:07:28 PM

Document Has Been Signed on 12/05/2024 12:07 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VALLEY VILLAGE ADULT DEVELOPMENT CENTERFACILITY NUMBER:
191222733
ADMINISTRATOR/
DIRECTOR:		SOUSAN AYYADFACILITY TYPE:
775
ADDRESS:20830/20834 SHERMAN WAYTELEPHONE:
(818) 587-9455
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY: 129CENSUS: 95DATE:
12/05/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Sousan Ayyad- administratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analysts (LPA) Leslie Ngo-Castaneda met with facility administrator Sousan Ayyad for a Plan Of Correction (POC) visit.

The purpose of the POC visit is to make sure deficiencies were corrected on reports issued on 10.22.2024.

Entrance interview conducted.

LPA toured the home and requested the following:

-CCR 82068(b)(1); 82068(b)(2) ; 82068(b)(3) ; 82068(b)(3)(A); 82068(b)(3)(B); 82068(b)(3)(C); 82068(b)(3)(D) - Missing admission agreement; 82068(b)(3)(E); 82068(b)(4) ; 82068(b)(5); 82068(b)(6); 82068(b)(7); 82068.2(b); 82068.2(f)(1)(C); 82068.2(f)(2); 82069(a); 82070(b)(8); 82070(b)(11)- Clients Records.

POC: Based on record review, the licensee did not comply with the section cited above in 1 count out of 1 documents in client chart which poses/posed a potential health, safety.

POC date 12.5.2024: POC Cleared during LPA visit.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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