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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197603303
Report Date:
12/10/2024
Date Signed:
12/10/2024 01:57:39 PM
Document Has Been Signed on
12/10/2024 01:57 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 DAY CARE - SUNLAND
FACILITY NUMBER:
197603303
ADMINISTRATOR/
DIRECTOR:
DONNA THOMAS
FACILITY TYPE:
775
ADDRESS:
8727 FENWICK STREET
TELEPHONE:
(818) 446-0366
CITY:
SUNLAND
STATE:
CA
ZIP CODE:
91040
CAPACITY:
80
CENSUS:
69
DATE:
12/10/2024
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:
Gary James, Program Director
TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts, (LPA) Leizl de la Cerra and LPA Leslie Ngo-Castaneda made an unannounced site visit to this facility as a continuation of the Required 1 Year Annual Inspection conducted on 07/10/2024. LPA met with program director, Gary James, and the purpose of visit was disclosed.
The following remaining inspection domains were observed, reviewed and inspected:
Client files:LPA conducted a file review for five (5) clients between 11:00AM to 1:00PM. While reviewing the records LPA observed various forms in client's files that were incomplete and/or missing required information such as admission agreement and physician's report.
Staff files: LPA conducted a file review for ten (10) staff members between 12:00 PM to 1:00PM.
For the deficiency observed (refer to LIC809-D). Exit Interview Conducted. Appeal Rights and a copy of this report issued.
SUPERVISORS NAME
:
Naira Margaryan
LICENSING EVALUATOR NAME
:
Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/10/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2024
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
7
Document Has Been Signed on
12/10/2024 01:57 PM
- It Cannot Be Edited
Created By:
Leizl De La Cerra
On
12/10/2024
at
12:48 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 DAY CARE - SUNLAND
FACILITY NUMBER:
197603303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on client record review, the licensee did not comply with the section cited above in 1 out of 1 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/24/2024
Plan of Correction
1
2
3
4
Administrator needs to complete admissions agreement before on boarding.
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 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/24/2024
Plan of Correction
1
2
3
4
Administrator needs to complete admissions agreement before on boarding.
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:
Naira Margaryan
LICENSING EVALUATOR NAME:
Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2024
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
12/10/2024 01:57 PM
- It Cannot Be Edited
Created By:
Leizl De La Cerra
On
12/10/2024
at
12:48 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 DAY CARE - SUNLAND
FACILITY NUMBER:
197603303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2024
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 1, the licensee did not comply with the section cited above in 1 out of 1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/24/2024
Plan of Correction
1
2
3
4
Administrator needs to complete admissions agreement before on boarding.
Type B
Section Cited
CCR
82068.2(f)(1)(B)
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: (B) A written medical assessment including primary physician, health problems and medical history, prescribed medications and their strength, quantity, frequency required and purpose as specified in Section 82069(b)(3).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review 1, the licensee did not comply with the section cited above in 1 out of 1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/24/2024
Plan of Correction
1
2
3
4
Provide medical assesment report.
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:
Naira Margaryan
LICENSING EVALUATOR NAME:
Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2024
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
12/10/2024 01:57 PM
- It Cannot Be Edited
Created By:
Leizl De La Cerra
On
12/10/2024
at
12:48 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 DAY CARE - SUNLAND
FACILITY NUMBER:
197603303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(h)(3)(D)
Needs and Services Plan
(3) This assessment shall also include, based on the information available at the time of the initial assessment, all of the following: (D) Preexisting medical conditions or any physical disabilities or limitations that would place the person at greater risk during restraint or seclusion.
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 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/24/2024
Plan of Correction
1
2
3
4
Provide medical assesment report.
Type B
Section Cited
CCR
82068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary, but at least annually, to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental, psychological, and/or social 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 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/24/2024
Plan of Correction
1
2
3
4
Provide medical assesment report.
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:
Naira Margaryan
LICENSING EVALUATOR NAME:
Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2024
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
12/10/2024 01:57 PM
- It Cannot Be Edited
Created By:
Leizl De La Cerra
On
12/10/2024
at
12:48 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 DAY CARE - SUNLAND
FACILITY NUMBER:
197603303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/24/2024
Plan of Correction
1
2
3
4
Provide medical assesment report.
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
1
2
3
4
Based on record review), the licensee did not comply with the section cited above in 1 out of 1 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/24/2024
Plan of Correction
1
2
3
4
Provide medical assesment report.
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:
Naira Margaryan
LICENSING EVALUATOR NAME:
Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2024
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
12/10/2024 01:57 PM
- It Cannot Be Edited
Created By:
Leizl De La Cerra
On
12/10/2024
at
12:48 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 DAY CARE - SUNLAND
FACILITY NUMBER:
197603303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2024
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 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/24/2024
Plan of Correction
1
2
3
4
Provide medical assesment report.
Type B
Section Cited
CCR
82071(a)(1)
Register of Clients
(a) The licensee shall maintain in the program site a register of all clients. The register shall be updated as needed; shall be immediately available to, and copied for, licensing staff upon request; and must contain current information on the following: (1) Client's name and ambulatory status as specified in Sections 82070(b)(1) and (8).
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 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/24/2024
Plan of Correction
1
2
3
4
Provide medical assesment report.
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:
Naira Margaryan
LICENSING EVALUATOR NAME:
Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2024
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
12/10/2024 01:57 PM
- It Cannot Be Edited
Created By:
Leizl De La Cerra
On
12/10/2024
at
12:48 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 DAY CARE - SUNLAND
FACILITY NUMBER:
197603303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/10/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82071(a)(4)
Register of Clients
(a) The licensee shall maintain in the program site a register of all clients. The register shall be updated as needed; shall be immediately available to, and copied for, licensing staff upon request; and must contain current information on the following: (4) Client's restricted health condition(s) as specified in Section 82092(b).
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 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/24/2024
Plan of Correction
1
2
3
4
Provide medical assesment report.
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:
Naira Margaryan
LICENSING EVALUATOR NAME:
Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:
DATE:
12/10/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/10/2024
LIC809
(FAS) - (06/04)
Page:
7
of
7