<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609963
Report Date: 03/09/2022
Date Signed: 03/10/2022 07:59:57 AM

Document Has Been Signed on 03/10/2022 07:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOMEFACILITY NUMBER:
197609963
ADMINISTRATOR:MARTY BACONFACILITY TYPE:
735
ADDRESS:6130 VINELAND AVETELEPHONE:
(818) 766-8161
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 58CENSUS: 41DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marty BaconTIME COMPLETED:
12:00 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
On 03/09/2022, at 9:30 a.m. Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. This annual inspection had a specific emphasis on infection control practices and procedures. LPA Urena met with Administrator Marty Bacon, and explained the reason for the visit.

Infection Control: Upon entry, the facility has a sign that directs the visitors to a central point to sign in, and have their temperature taken. Sanitizer dispensers are located throughout the facility. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

At 9:45 a.m., LPA Urena and Administrator Marty Bacon conducted a tour inside and outside of the facility to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations.

Common Areas: At 10:00 a.m., LPA Urena observed the walls and flooring to be clean and in good condition. At the time of the visit, common seating area, and dining room furniture was observed to be in good condition. Fire extinguishers were observed to be serviced within the last year.

Bedrooms: At 10:15 a.m., LPA Urena observed the residents’ bedrooms. Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens appeared to be clean and in good condition.

Continues on LIC809C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/09/2022
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
26
27
28
29
30
31
32
Bathrooms: At 10:30 a.m., LPA Urena observed the residents’ bathrooms. Bathrooms are equipped with toilet and sink. Paper towels were available for drying hands. There are communal shower areas, which were observed to be clean. Residents are provided with clean towels as they prepare to use the shower area. A used towel receptacle is located inside the shower area for residents to deposit their used towels. Handwashing signs were displayed in each bathroom, and sufficient amounts of soap and paper products in each restroom.

Outdoor Space: At 10:45 a.m., LPA Urena observed the outdoor space. The area has a shade for residents to sit outdoors, and furniture for residents’ use. There were no bodies of water noted.



Kitchen: At 11:00 a.m., LPA Urena observed the kitchen area which located in the Skilled Nurse Facility (SNF), which is located in a building next door to the facility. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Temperature of refrigerators, and freezers were within the regulations: below 40 degrees Fahrenheit, and below 0 degrees Fahrenheit.


No deficiencies were cited during this visit. Exit interview was conducted. The report was reviewed with licensee representative Marty Bacon. Signatures were obtained, and a copy of the report was provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2