191222733-11-3-2025-31-AS-PKHN-DN3TBS-20251103133538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222733
Report Date: 11/03/2025
Date Signed: 11/03/2025 01:36:55 PM

Document Has Been Signed on 11/03/2025 01:36 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 CENTER		FACILITY NUMBER:	191222733
ADMINISTRATOR/ DIRECTOR:	SOUSAN AYYAD		FACILITY TYPE:	775
ADDRESS:	20830/20834 SHERMAN WAY		TELEPHONE:	(818) 587-9455
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY: 129		CENSUS: 109	DATE:	11/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:17 AM
MET WITH:	Michael Florita - Program Director		TIME VISIT/ INSPECTION COMPLETED:	01:50 PM

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On 11/3/2025, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a required Annual Inspection. Upon arrival the LPA introduced herself by showing her department badge, was greeted by the Program Directors Sarah Mangual and Michael Florita. LPA explained the reason for the visit and requested staff and residents’ rosters for review.

LPA Khurshudyan reviewed the required postings on a wall and used the inspection tool to complete today's visit. A tour of the physical plant was conducted at around 10:30am and the following were noted:

This facility is operating as Adult Day Program and is fire cleared for one hundred twenty-nine (129) Non-Ambulatory clients. The facility is currently occupying one hundred nine (109) clients. There are four (4) entrances being utilized at the facility. The property consists 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 Facility has one elevator which operates properly.

The Ground floor has total of ten (10) activity rooms: Music, Art, Sensory, Physical activities, Communication, etc. The program provides community-based activities. The activity rooms were nicely furnished and equipped with various activity supplies. The activity schedules were posted and available for clients. There is also a large dining and kitchen area. LPA was informed that clients bring their own lunches, and the cooking area gets barely used for special occasions only. LPA observed four (4) refrigerators, however, no fresh or frozen foods were stored inside the fridges. LPA observed clients’ lunch boxes and staff food were stored inside the fridges. Food storage and preparation areas were clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VILLAGE ADULT DEVELOPMENT CENTER	FACILITY NUMBER: 191222733
	VISIT DATE: 11/03/2025

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There are eight (8) bathrooms / changing rooms in the facility, ground floor has separate bathrooms for male and female clients. The facility has enough hygiene products for clients. The bathrooms were checked for cleanliness and proper operations. Hot water temperature measured 107.9 degrees Fahrenheit.
The facility maintains a comfortable temperature at 73°F. The smoke and carbon monoxide detectors are hardwired, interconnected and centralized with automatic dispatch to the Los Angeles Fire Department. Fire extinguishers were located throughout the facility and observed to be fully charged and last inspected on 06/15/2025. LPA observed at least eight (8) fire extinguishers throughout the facility.

The facility has one (1) laundry room which was observed to be unlocked; however, no laundry detergent was stored inside the laundry room. Cleaning supplies, chemicals and detergents are stored inside the locked cabinets and inaccessible to residents, however, during walk through LPA observed Clorox wipes were left outside inside female clients’ bathroom.

The facility does not have a swimming pool or body of water. All pathways are clear of obstruction. The facility provides an outdoor area and patio with an appropriate furniture for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water.

The medications / over the counter medications are centrally stored inside the locked cabinets located in the nursing station. LPA observed properly labeled medications and residents’ medical files to be locked and inaccessible to residents in care. Proper medication dispensing instructions are followed and checked for contamination. The facility maintains a complete first aid kit with current manual.

Between 11:30am -12:45pm LPA conducted records review of five (5) staff files and ten (10) clients records. LPA reviewed client’s files for current IPP’s and other required documentation. LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. LPA reviewed files review for criminal record clearances, current First Aid, and other required documentation. Files were complete and updated.

LPA collected LIC500, LIC9020, and copy of Liability Insurance Exp : 3/22/2026 No health and safety hazards noted during today’s visit.

Citations issued during today's visit, see LIC809-D.
Exit interview conducted. Copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/03/2025 01:36 PM - It Cannot Be Edited

Created By: Perchui Khurshudyan On 11/03/2025 at 01:03 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: 11/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82087(a)(3)

Buildings and Grounds

(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by leaaving Clorox wipes / chemical unsupervised inside the clients bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/07/2025
	Plan of Correction
1 2 3 4	Program Director immediately moved and locked the chemical inside the cabinet and will submit in-service/ training material to LPA by POC due date.

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.

	Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:

	Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/03/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2025

LIC809 (FAS) - (06/04)

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