197609963-11-23-2022-29-AS-DPEA-CLLVHB-20221128152654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609963
Report Date: 09/28/2021
Date Signed: 11/23/2022 12:21:10 PM

Unsubstantiated

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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2020 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20201112101531

FACILITY NAME:	VALLEY MANOR GUEST HOME		FACILITY NUMBER:	197609963
ADMINISTRATOR:	MARTY BACON		FACILITY TYPE:	735
ADDRESS:	6130 VINELAND AVE		TELEPHONE:	(818) 766-8161
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	58	CENSUS: 49	DATE:	09/28/2021
		UNANNOUNCED	TIME BEGAN:	01:03 PM
MET WITH:	Marty Bacon Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained unexplained injuries
Lack of supervision resulting in resident leaving the facility
Illegal eviction

INVESTIGATION FINDINGS:

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**This is an amended report to included additional information and clarification for the allegation of illegal eviction.**Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the above allegations. LPA met with Administrator Marty Bacon and explained the reason for the visit.

During the course of the investigation, LPA conducted a physical plant tour virtually on 11/19/2020 as well as interviewed Administrator. On 9/10/2021 LPA conducted interviews with facility staff, and other relevant parties. LPA also gathered and reviewed facility documentation pertinent to the allegation.

In regards to the allegation that Resident sustained unexplained injuries. LPA records review revealed that Resident 1 (R1) was discovered laying in their room on 10/23/2020 at 1:25pm. It was documented and reported to licensing on 10/23/2020. In the report, it was stated that after first aid was rendered to R1 at the time of the fall a cut was discovered on R1's right eyebrow. Staff then assisted R1 back into bed and 911 was called and R1 was discharged to a local hospital.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20201112101531

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY MANOR GUEST HOME	FACILITY NUMBER: 197609963
	VISIT DATE: 09/28/2021

NARRATIVE

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Continued from 9099

Interview with Administrator and responsible parties with knowledge of the situation revealed that R1 later informed staff that R1 fell because they suddenly felt weak attempting to get out of bed. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that resident sustained unexplained injuries. Therefore the above allegation is UNSUBSTANTIATED at this time.

It was alleged that lack of supervision resulting in resident leaving the facility. LPA records review of R1's physician's report revealed, that R1 was able to leave facility unassisted and did not require 1:1 care supervision. LPA interview with staff and other responsible parties revealed that R1 may have been in the smoking area near the parking lot of the facility and then exited the premises through the gate. Interviews further revealed that R1 would leave facility on occasion, to go to the store, but R1 would always return. LPA schedule review revealed there to be sufficient amount of staffing at the time R1 eloped from the facility. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that there was lack of supervision resulting in resident leaving the facility. Therefore the above allegation is UNSUBSTANTIATED at this time.

It was alleged that Resident #1 (R1) was illegally evicted. It was reported that R1 was being evicted from the facility. Interviews conducted revealed that R1’s responsible parties visited R1 in the hospital on 11/9 following the incident. Interviews with the responsible parties and hospital staff revealed that R1 required a higher level of care and supervision than what the facility could offer. On 11/16 R1 was discharged to a local Skilled Nursing Facility. It was further revealed that the Administrator kept all of R1s personal belongings in R1s room throughout R1s hospital stay until discharge to Skilled Nursing Facility. Additionally, record review revealed there was no eviction notice in file and no eviction notices was submitted to Community Care Licensing (CCL) for R1. Based on interviews and information gathered and reviewed, the Department does not have sufficient evidence to support the allegation of “illegal eviction”. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report issued and sent via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

LIC9099 (FAS) - (06/04)

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