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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609963
Report Date: 02/07/2023
Date Signed: 02/07/2023 04:03:59 PM

Document Has Been Signed on 02/07/2023 04:03 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 NORTH, 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: 49DATE:
02/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Martha Bacon, AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required annual inspection, with emphasis on the infection control procedures practices and met with Martha Bacon. The reason for today's visit was explained.

Upon entry into the facility on today's visit at 8:30am, LPA Yee observed posters that advises residents and visitors to wear a mask when entering the facility in the front and back entry way, temperature is taken in the center office where visitors are directed to sign in. A tour was conducted of the facility from 12:30pm - 1:30pm, inside and outside. The following rooms were randomly chosen and inspected - Room 105, 113, 114, 117, shower #1 and #2. The following were observed:
  • A large hole was observed in the ceiling in shower #1
  • the wooden beam and ceiling in the dining room have water damage
  • hand sanitizers are installed throughout the hallways
  • hand washing instructions were posted in the hallway
  • the facility has sufficient supply of Personal Protection Equipment (PPE) for approximately 30 days and has a supplier for additional PPEs if needed.
  • Overall, the facility was observed to be clean and is cleaned and sanitized everyday. The rooms inspected and common areas were clean.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY MANOR GUEST HOME
FACILITY NUMBER: 197609963
VISIT DATE: 02/07/2023
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  • The smoke detector was tested in room 113 and was operational
  • The fire extinguishers were last inspected on 10/13/22
  • The medications were centrally stored in a locked room
  • The linen closet was inspected and plenty of bed linens was observed
  • The outside area in the parking lot was clean and set up with chairs and umbrellas for residents who smoke and a gazebo for residents and visitor
  • The facility does not have a kitchen. The facility has a food contract with the skilled nursing next door and cooked food is brought over at meal times. Observed in a locked room, was a supply of dehydrated food for emergencies. A tour of the kitchen in the SNF was conducted at 2:01pm and lots of dehydrated foods were observed for emergencies. Also observed were cans of tomato sauces and paste, pasta, rice, canned fruits, refried beans, tuna and dehydrated potato chips. Insufficient perishables were observed. Per SNF staff, they have a delivery coming in tomorrow - 2/8/23.

Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Any deficiencies not cited on today's visit, will be cited on a return visit.

Exit interview was conducted with Martha Bacon and a copy of the report was provided and Appeals rights were discussed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
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Document Has Been Signed on 02/07/2023 04:03 PM - It Cannot Be Edited


Created By: Christine Yee On 02/07/2023 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY MANOR GUEST HOME
FACILITY NUMBER: 197609963

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operations:
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by:
Shower #1 was observed with a large hole in the ceiling and the wood beam and ceiling in the dining room was observed with warped and had water damage
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in and is out of compliance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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The licensee will submit a plan of action that will provide a time and date when the hole in the ceiling and the water damage in the dining room will be fixed by 2/10/23 and Provide evidence that the damage has been fixed by 2/17/23
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Pfannenstiel
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023


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