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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197600430
Report Date: 06/26/2024
Date Signed: 06/26/2024 11:23:51 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-NP-20220613164253
FACILITY NAME:VALLEY VIEW RETIREMENT CENTERFACILITY NUMBER:
197600430
ADMINISTRATOR:JUDITH MONTOYAFACILITY TYPE:
740
ADDRESS:7720 WOODMAN AVE.TELEPHONE:
(818) 997-6756
CITY:PANORAMA CITYSTATE: ZIP CODE:
91402
CAPACITY:116CENSUS: 58DATE:
06/26/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Judith Montoya TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Failure to observe resident

Failture to seek timely medical attention
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. LPA met with the Administrator and explained the reason for the visit.

During the initial visit on 6/21/2022, between 12:30 p.m. and 4:40 p.m., LPA Peraldi conducted a facility tour and reviewed records and obtained copies of pertinent documents. The LPA also conducted interviews with the Administrator, residents, and staff. On 06/11/2024, the LPA conducted a file review of Resident #1 (R1’s) documents such as but not limited to, admission agreement, and medical records.

Regarding the allegations: Failure to observe resident. Failure to seek timely medical attention. It was alleged that the facility did not properly observe Resident #1’s (R1’s) condition and failed to seek timely medical attention by not following up on R1’s doctor’s appointments and lab work and not communicating with R1’s responsible party.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-NP-20220613164253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY VIEW RETIREMENT CENTER
FACILITY NUMBER: 197600430
VISIT DATE: 06/26/2024
NARRATIVE
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Per record review, R1’s admission agreement, dated and signed 01/02/2020 stated that resident requires or desires assistance in meeting medical and dental needs. Interview conducted with the Administrator from another complaint relating to R1, dated 03/04/2022 stated that R1 went to doctor’s appointments by themselves and R1 did not communicate with facility staff regarding R1’s doctor’s appointments or aftercare. Administrator stated that R1 was independent and dealt with medical care by themselves. However, it was revealed during a record review that R1 had a California Advance Health Care Directive and a Power of Attorney (POA) and in the document R1 stated that R1 wants R1’s agent to make health care decisions now even though R1 currently had the mental capacity to make own health care decisions; document signed and dated 02/25/2016. Interview conducted with the Administrator from another complaint relating to R1, dated 03/04/2022 stated that the facility did not have a copy of R1’s POA paperwork stating that R1 had a medical POA. Additionally, R1 was enrolled in the Assisted Living Waiver Program (ALW) and it was documented on R1’s Individual Service Plan (ISP) dated 06/26/2020 that R1 does not understand all medical appointment necessary to manage R1’s multiple medical diagnoses. The ISP continues stating, “Under medical supervision, participant’s active diagnosis will remain under control with no disease progression. RCFE and participant will work together to identify all medical specialists required to address all active diagnoses. RCFE will assist participant with scheduling all follow up appointments and lab work ordered by MD.” Although facility staff believed R1 was independent and was capable of caring for R1’s own medical care, R1 did need assistance with arranging medical care and the facility staff should have communicated with R1’s POA/ responsible person regarding R1’s medical care and needs. Furthermore, facility staff should have maintained proper paperwork that was essential to observing R1 and ensuring that R1’s medical needs would be met. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are deemed Substantiated.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-NP-20220613164253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VIEW RETIREMENT CENTER
FACILITY NUMBER: 197600430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2024
Section Cited
CCR
87466
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 87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided when such observation reveals unmet needs...responsible person, if any. This requirement is not met as evidenced by:
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Administrator stated that she will submit a plan on how to ensure staff monitor residents for any change in condition and ensure that arrangement of medical care is proper and submit a plan of staff training regarding above regulation
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Based on interviews and record review, the licensee did not comply with the section cited above by not ensuring R1’s medical care being arranged and followed which posed an immediate health and safety risk to residents in care.
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-NP-20220613164253

FACILITY NAME:VALLEY VIEW RETIREMENT CENTERFACILITY NUMBER:
197600430
ADMINISTRATOR:JUDITH MONTOYAFACILITY TYPE:
740
ADDRESS:7720 WOODMAN AVE.TELEPHONE:
(818) 997-6756
CITY:PANORAMA CITYSTATE: ZIP CODE:
91402
CAPACITY:116CENSUS: 58DATE:
06/26/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Judith Montoya TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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9
Failure to comply with reporting requirements

Conduct inimical

Failure to report COVID-19 outbreak
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. LPA met with the Administrator and explained the reason for the visit.

During the initial visit on 6/21/2022, between 12:30 p.m. and 4:40 p.m., LPA Peraldi conducted a facility tour and reviewed records and obtained copies of pertinent documents. The LPA also conducted interviews with the Administrator, residents, and staff. On 06/11/2024, the LPA conducted a file review of Resident #1 (R1’s) documents and facility records.

Regarding the allegation: Failure to comply with reporting requirements. It was alleged that the facility staff did not report any change of condition of R1 to R1’s Power of Attorney (POA)/ responsible person. Per record review, R1 did not have a significant change of condition prior to R1’s death
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-NP-20220613164253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY VIEW RETIREMENT CENTER
FACILITY NUMBER: 197600430
VISIT DATE: 06/26/2024
NARRATIVE
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The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Conduct inimical. It was alleged that facility staff purposely ignored R1’s medical care and needs. Although facility staff did not have proper documents such as California Advance Health Care Directive and a Power of Attorney (POA) for R1 in order to provide proper care and supervision, the LPA could not determine that the facility staff purposely ignored R1’s medical care needs. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Failure to report Covid-19 outbreak. It was alleged that the facility had a Coronavirus Disease 2019 (COVID-19) outbreak during November 2020 and failed to report to appropriate agencies. The complainant alleged that the facility was on lock down during the month of November 2020. Record review revealed that COVID-19 was reported to Community Care Licensing on December 10, 2020. It was reported that the initial COVID-19 test were conducted on December 6, 2020, and results came in on December 8, 2020. There was no further documentation of an outbreak prior to December 2020. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5