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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609061
Report Date: 10/14/2020
Date Signed: 10/14/2020 03:27:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:WEST VALLEY ASSISTED LIVINGFACILITY NUMBER:
197609061
ADMINISTRATOR:MILLAN, JONATHANFACILITY TYPE:
740
ADDRESS:7055 SHOUP AVENUETELEPHONE:
(818) 883-7201
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:90CENSUS: 50DATE:
10/14/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jonathan MillanTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Desaree Perera made an unannounced Case Management - Deficiencies to the above facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s case management visit was conducted telephonically with Jonathan Millan at 2:45pm. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation (Complaint control # 31-AS-20200408163152) which were not related to the complaint. Entrance interview conducted.
During the above listed complaint investigation, it was revealed that the facility does not have a qualified cook or an activities director with any formal training and/or experience; nor did the facility have a qualified dietician or nutritionist to provide consultation regarding the meals that are provided to the residents. Furthermore, it was revealed that the facility activities director, laundry personnel and dishwasher also take on the role of the facility cook. Interviews conducted with administrator on 04/20/2020 at 8:59am, 07/23/2020 at 11:52am and on 07/28/2020 at 11:00am, revealed that facility staff responsible for cooking; and, the Activity Director, do not have the required training to perform the respective jobs.

Continued on LIC809-C..
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: WEST VALLEY ASSISTED LIVING
FACILITY NUMBER: 197609061
VISIT DATE: 10/14/2020
NARRATIVE
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Moreover, the administrator stated that the facility did have a dietician come in to provide guidance once; however, was not able to provide any reports or information for the consultant. The administrator further stated that the facility is currently going through a management change and a qualified dietician will be hired to provide consultation and all staff will be provided with the required training.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit Interview Conducted / Citations issued /Appeal Rights Discussed / A copy of report was sent via email for signature.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: WEST VALLEY ASSISTED LIVING
FACILITY NUMBER: 197609061
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2020
Section Cited

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Personnel Requirements – General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...Additional staff shall be employed...perform office work, cooking...This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the above section by not hiring additional staff to perform the necessary job functions such as cooking, activities, and laundry; which is a potential health, safety and personal rights risk to residents in care.
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Type B
10/21/2020
Section Cited

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General Food Service Requirements. (b) The following food service requirements shall apply: (17) In facilities licensed for fifty (50) or more... three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service... This requirement is not met as evidenced by:
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Based on interviews and record review, licensee did not comply with the above section by employing individuals who are not qualified training or experience to perform as a cook and not having a regular qualified person providing consultation as needed, which is a potential 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: WEST VALLEY ASSISTED LIVING
FACILITY NUMBER: 197609061
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2020
Section Cited

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87219(f) Planned Activities. (f) In facilities licensed for fifty (50) persons...one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance...participate in accordance with their interests and abilities... This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the above section employing an individual with no qualifications or experience to perform the planned activities, which is a potential health, safety and personal rights risk to residents in care.
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Type B
10/28/2020
Section Cited

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Administrator - Qualifications and Duties. (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
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Based on interviews conducted, the licensee did not comply with the above section due to administrator not having the knowledge of the regulations and employing staff who are not qualified or experienced to perform job duties such as activities and cooking, which is a potential health, safety and personal rights 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4