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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609061
Report Date: 12/15/2020
Date Signed: 12/21/2020 09:00:29 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2020 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20201210101935
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: 44DATE:
12/15/2020
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Jonathan MillanTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident 1 (R1) was issued an unlawful Eviction Notice
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Yelena Avetisyan initiated a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was initiated Virtually at 2:55 pm with Administrator Jonathan Millan.

It is being alleged that the eviction notice given to Resident 1 (R1) is unlawful. Prior to this visit LPA conducted review of the eviction noticed to R1 and spoke with administrator regarding the eviction. Information obtained during the course of the eviction revealed that the eviction notice issued to R1 was incomplete and missing the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.

Based on the information obtained the allegation is Substantiated at this time.

A telephonic exit interview was conducted/ Copy was provided via email for signature.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020
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 2
Control Number 31-AS-20201210101935
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: 12/15/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/21/2020
Section Cited
CCR
87224(d)
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(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.

This requirement was not met as evidenced by:
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Mr Millan agreed to review regulation 87224 and re-issue a proper and complete eviction notice to R1. Copy of the eviction notice will need to be submitted as POC.
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Based on review of the eviction notice issued to R1 which reveled that the eviction notice was missing information as required by Section 87224 which poses a potential personal rights risk to R1.
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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 HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020
LIC9099 (FAS) - (06/04)
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