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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
197609061
Report Date:
08/31/2021
Date Signed:
08/31/2021 03:24:30 PM
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., STE. 250
WOODLAND HILLS
,
CA
91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2020
and conducted by Evaluator
Wendell Smith
COMPLAINT CONTROL NUMBER:
31-AS-20200911101236
FACILITY NAME:
WEST VALLEY ASSISTED LIVING
FACILITY NUMBER:
197609061
ADMINISTRATOR:
MILLAN, JONATHAN
FACILITY TYPE:
740
ADDRESS:
7055 SHOUP AVENUE
TELEPHONE:
(818) 883-7201
CITY:
WEST HILLS
STATE:
CA
ZIP CODE:
91307
CAPACITY:
0
CENSUS:
40
DATE:
08/31/2021
UNANNOUNCED
TIME BEGAN:
01:35 PM
MET WITH:
TIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is falsifying documents
Staff are engaging in gambling with residents
Resident fell while in care and sustained injury
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegations above. LPA met with the adminstrator and explained the reason for this visit.
Facility is falsifying documents
It is alleged that facility falsified documents related to resident #1 (R1) care and wanted R1 to sign them. LPA had previously conducted visits on 9/16/2020 and 10/23/2020 and gathered information and conducted interviews with facility staff and R1. Information obtained through interviews revealed that there was an application for R1 to enter into the assisted living waiver program but that R1 did not want to do the program and did not want to fill out the paperwork. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/31/2021
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
4
Control Number
31-AS-20200911101236
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., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
WEST VALLEY ASSISTED LIVING
FACILITY NUMBER:
197609061
VISIT DATE:
08/31/2021
NARRATIVE
1
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3
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5
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8
9
10
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12
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14
15
16
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21
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Staff are engaging in gambling with residents
It is alleged that staff # 1(S1) was engaged in gambling with the residents. From approximately 1:50pm-2:15 pm LPA conducted interviews with various residents and S1 regarding this allegation. Information from interviews reveal that during activities one of the games was a card game named Black Jack and that chips were used. No used any real money and it was just a card game. Based on the interviews conducted this allegation is deemed Unsubstantiated at this time.
Resident fell while in care and sustained injury
It is alleged that resident #1 (R1) sustained a fall due to water fountain leak. LPA previously conducted an phone interview with R1 regarding the allegation. R1 stated they do not remember anything about falling due to a water fountain leak. Information obtained from the administrator the facility doesn't have a water fountain. LPA conducted a physical plant walk through from approximately 1:40-1:50 pm and did not observe any water fountain. Based on the information obtained this allegation is deemed Unsubstantiated at this time.
Exit Interview conducted.
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/31/2021
LIC9099
(FAS) - (06/04)
Page:
2
of
4
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., STE. 250
WOODLAND HILLS
,
CA
91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2020
and conducted by Evaluator
Wendell Smith
COMPLAINT CONTROL NUMBER:
31-AS-20200911101236
FACILITY NAME:
WEST VALLEY ASSISTED LIVING
FACILITY NUMBER:
197609061
ADMINISTRATOR:
MILLAN, JONATHAN
FACILITY TYPE:
740
ADDRESS:
7055 SHOUP AVENUE
TELEPHONE:
(818) 883-7201
CITY:
WEST HILLS
STATE:
CA
ZIP CODE:
91307
CAPACITY:
0
CENSUS:
40
DATE:
08/31/2021
UNANNOUNCED
TIME BEGAN:
01:35 PM
MET WITH:
Jonathan Millan
TIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Front door in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegations above. LPA met with the adminstrator and explained the reason for this visit.
Regarding the allegation above it is alleged that the front door was not working properly. LPA conducted an interview with the administrator regarding this allegation. Administrator stated that there was an issue with a pad lock on the front door which would not open and close right. Administrator stated that it has since been fixed for over a year. LPA during a physical plant walk through observed the front door to be operating properly. Based on the information obtained through interviews this allegatiosn is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099
(FAS) - (06/04)
Page:
3
of
4
Control Number
31-AS-20200911101236
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., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
WEST VALLEY ASSISTED LIVING
FACILITY NUMBER:
197609061
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2021
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Corrected before visit. Front door has been fixed.
8
9
10
11
12
13
14
Based on information obtained during interviews the front door was not opening properly which could pose a health and safety risk to residents in care.
8
9
10
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13
14
1
2
3
4
5
6
7
1
2
3
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5
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7
1
2
3
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5
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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:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
08/31/2021
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/31/2021
LIC9099
(FAS) - (06/04)
Page:
4
of
4