197600430-3-18-2022-29-AS-KHEN-CCRV5N-20220322160813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197600430
Report Date: 03/18/2022
Date Signed: 03/18/2022 10:55:20 AM

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
06/18/2021 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20210618161840

FACILITY NAME:	VALLEY VIEW RETIREMENT CENTER		FACILITY NUMBER:	197600430
ADMINISTRATOR:	JUDITH MONTOYA		FACILITY TYPE:	740
ADDRESS:	7720 WOODMAN AVE.		TELEPHONE:	(818) 997-6756
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	116	CENSUS: 73	DATE:	03/18/2022
		UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Judith Montoya, Administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not provide a copy of resident's records to resident's representative in a timely manner

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced subsequent complaint visit to this facility. At 10:07 a.m., LPA met with the Administrator and explained the reason for the visit.

During the initial visit on 06/23/2021, LPA Emily Peraldi interviewed the Administrator and seven (7) out of seventy-four (74) residents and requested pertinent documents. On 10/14/2021, LPA Peraldi toured the facility, interviewed the Administrator and received copies of requested documents.

Regarding the allegation: Facility staff did not provide a copy of resident's records to resident's representative in a timely manner.

Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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 3

Control Number 29-AS-20210618161840

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: 03/18/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 06/18/2021, it was alleged that the facility did not provide a copy of resident’s records to Resident #1’s (R1’s) representative in a timely manner. To investigate on 06/23/2021, 10/12/2021 and 10/14/2021, LPA Peraldi conducted record reviews of pertinent documents. In addition, on 06/23/2021 and on 10/14/2021, LPA Peraldi interviewed the Administrator. The interview with the Administrator revealed that the facility had faxed over the R1’s records to R1’s representative on time but that R1’s representative never received it. The facility sent R’1s records again on 06/17/2021 via email to R1’s representative. Additionally, LPA Peraldi conducted an interview and requested documents from R1’s representative on 10/12/2021. The record review conducted on 10/12/2021, revealed that R1’s representative requested for R1’s records on 06/08/2021 and on 06/21/2021 records were received via email.

Per regulation, the facility is required to provide prompt access to review all of resident’s records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. Per record review and interviews, the facility did not provide copies of R’1s records to R1’s representative within the two (2) business days’ time frame.

Based on the information obtained, there is sufficient evidence to support the claim that facility did not provide R1’s records to R1’s representative in a timely manner. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview conducted and report reviewed with Administrator. A copy of reports and appeal rights will be emailed.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20210618161840

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: 03/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/23/2022 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	87468.2: Additional Personal Rights of Residents in Privately Operated Facilities. (19)To have prompt access to review all of their records...Photocopied records shall be provided within two (2) business days...This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee agreed to do the following: An in-service training to be held with administrative staff in regard to regulation 87468.2 (a)(19). Sign-in sheet and appropriate documents to be submitted by 03/23/2022.
	8 9 10 11 12 13 14	Based on record review and interviews, the licensee did not comply with the section cited above, as the facility failed to provide R1’s records to R1’s representative in a timely manner, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3