197609869-1-25-2024-29-AS-EPEI-CZTRTZ-20240125121910

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609869
Report Date: 01/25/2024
Date Signed: 01/25/2024 12:19:42 PM

Document Has Been Signed on 01/25/2024 12:19 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VALLEY VILLA SENIOR LIVING		FACILITY NUMBER:	197609869
ADMINISTRATOR:	SIMITYAN, ARMENUI		FACILITY TYPE:	740
ADDRESS:	8315 SPARTON AVE		TELEPHONE:	(818) 994-5223
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 4	DATE:	01/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Armenui Simityan, Administrator		TIME COMPLETED:	12:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:35 a.m., the LPA met with staff and explained the reason for the visit. At 10:37 a.m., the Administrator, Armenui Simityan arrived at the facility. At 11:05 a.m., the LPA, along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. OUTDOOR SPACE: At 11:10 a.m., the LPA observed the back patio which has a covered outdoor area for resident use. There are gates on each side of the house designated for an emergency exits. Passageways were free and clear from obstruction. There are no bodies of water on the premises. The garage is attached to the house and remains inaccessible to residents. BEDROOMS: The facility is a single-story residential home with six (6) bedrooms, five (5) for resident use and one (1) for staff use and three (3) bathrooms. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Starting 11:25 a.m., hot water measured between 105.1 and 107.2-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the restroom cabinets. Continued on LIC-809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VILLA SENIOR LIVING	FACILITY NUMBER: 197609869
	VISIT DATE: 01/25/2024

NARRATIVE

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KITCHEN: The LPA observed the kitchen and dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:35 a.m., hot water measured at 106.6-degree Fahrenheit. Laundry units are located next to the kitchen. Cleaning solutions and chemical items were inaccessible and locked away inside cabinets in the laundry area.

COMMON AREAS: The LPA observed common areas to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 09/27/2023. At 11:32 a.m., fire alarms/carbon monoxide detectors were tested and functioned properly. All exits have functioning auditory devices and were operational at the time of the visit. Facility telephone was observed during the time of the visit. Medications and first aid kits are located in a locked storage closet near the activity room.

Starting at 10:08 a.m., the LPA conducted interviews with two (2) out of four (4) residents and one (1) staff.

During the time of the visit, the LPA requested the following documents: Emergency Disaster Plan, Infection Control Plan, LIC 9020A, LIC 308, and LIC 500.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC809 (FAS) - (06/04)

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