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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603303
Report Date: 10/28/2021
Date Signed: 10/28/2021 12:21:52 PM

Document Has Been Signed on 10/28/2021 12:21 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VALLEY VILLAGE ADULT DAY CARE - SUNLANDFACILITY NUMBER:
197603303
ADMINISTRATOR:DONNA THOMASFACILITY TYPE:
775
ADDRESS:8727 FENWICK STREETTELEPHONE:
(818) 446-0366
CITY:SUNLANDSTATE: CAZIP CODE:
91040
CAPACITY: 80CENSUS: 14DATE:
10/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Debra Donovan, Gary James, Jose HernandezTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a Case Management and met Executive Director Debra Donovan, Program Directors Gary James and Jose Hernandez; all were informed the reason of the visit. Licensing received a special incident report (SIR) involving a staff using inappropriate language to a client. LPA also discussed with Administration, the SIR was not submitted to Licensing in a timely manner and according to regulations. The incident reported was dated 08/23/2021; but was not submitted to Licensing until October 15, 2021.

According to the SIR, a facility staff, made an inappropriate statement to a client, while under the staff's supervision. LPA contacted the facility to obtain further information, pertaining to the incident. According to the Administrator, the staff was placed on administrative leave, until the facility's internal investigation was completed. The investigation was conducted and completed, and the staff was terminated, and is currently no longer employed with the facility. It was determined, that the staff made the inappropriate statement, therefore, resulting in the termination of employment. During today's visit, LPA interviewed the facility's Administrators and obtained further information pertaining to the incident. LPA will discuss with management regarding possible further action. A citation will be issued during this visit, for not submitting the SIR in a timely manner. The plan of correction will be also be cleared, due to the discussion with Administrators, and submitting documents requested by LPA.

Exit interview conducted, appeals, and copy of report provided to the Executive Director.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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Document Has Been Signed on 10/28/2021 12:21 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 10/28/2021 at 12:00 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: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2021
Section Cited
CCR
82061(a)

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Reporting Requirements.(a) ...during the hours the day program is providing services to the client...a report shall be made to the licensing agency within...its normal business hours...a written report containing...
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POC cleared, a discussion with the Executive Director was conducted regarding reporting requirements, and LPA received requested documentation pertaining to the incident. The ED ensured LPA
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...within seven days following the occurrence of the event. This requirement was not met, evidenced by, a SIR was received 10/15/2021 and the incident occured 08/23/2021. This is a potential health and safety risk to clients in care.
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that all SIRs will be submitted in a timely manner.

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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:Cassandra Harris
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021


LIC809 (FAS) - (06/04)
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