197609963-3-14-2023-29-AS-CYEE-CPWTYD-20230314150834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609963
Report Date: 03/14/2023
Date Signed: 03/14/2023 03:10:00 PM

Document Has Been Signed on 03/14/2023 03:10 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 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: 48	DATE:	03/14/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Martha Bacon, Administrator		TIME COMPLETED:	03:30 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) Christine Yee conducted an unannounced case management visit due to the death of Resident #1 on the morning of 3/10/23. The death of Resident #1 was reported to LPA Yee by Martha Bacon on 3/13/23 via telephone and a little later, followed up with an emailed copy of the Death Report (LIC624A) and requested documents. Today's visit was conducted with Martha Bacon, Administrator, who was advised of the reason for the visit. On today's visit, LPA Yee conducted interviews with the Administrator at 12:18pm, Hector Gomez, Assistant Administrator at 1:31pm, Staff #1 at 1:53pm, toured the site of the accident at 11:54am and reviewed Resident's file at 2:10pm. Roommate was sleeping and could not be interviewed and would not be a credible witness. Per information that was provided to LPA Yee by Martha Bacon, Administrator, she was the one that served breakfast to Resident #1 between 7:45am - 8am on 3/10/23. After breakfast, Resident #1 left the facility and headed north on Vineland Avenue and approximately 150 feet away from the facility, was hit by a vehicle. Office staff were immediately made aware of an accident that had just occurred by the residents and a staff who lives in the area. No one was aware Continued on LIC809-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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 3

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: 03/14/2023

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

of who was involved in the accident. A resident who went to enquire about the
accident returned to the facility with a police officer around 10:30am. The administrator informed the officer that they had conducted a head count and two residents were not on-site. One resident was confirmed to be visiting a family member who lived close by and the whereabouts of Resident #1 was unknown at that time. The officer took a photograph of Resident #1's picture with a cell phone and left. The officer never returned to notify staff if the accident victim was Resident #1. The identity of the accident victim was not revealed to the facility staff until 3/11/23, around 4:00pm by a family member. Weekend staff were also in the process of filing a missing person's report for Resident #1 around 3:10pm and were placed on hold for 45 minutes to an hour when family called to notify staff of the death. Family member also requested a refund of the rent. The call to file a missing person report was canceled when the facility was notified of Resident #1's death.

Per interviews conducted with staff, Resident #1 was behaving normal on 3/10/23, had a full breakfast, smoked, played loud music and was singing like usual. Resident #1 did not complain of any health issues. Resident #1 did not exhibit any suicidal ideations. Per review of the resident's file, resident is allowed to leave the facility without supervision.

The Administrator, made contact with Resident #1's conservator on 3/13/23 and discussed the disposition of Resident #1's belongings and the refund of the prorated rent and P and I money. The Administrator was instructed to donate resident's belongings. The pro-rated rent and P and I money is going to be

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 03/14/2023

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

refunded to the conservator and not the inquiring family member. Medications will be destroyed.

The facility will obtain a copy of the police report and a copy of the death certificate from the conservator and submit to Licensing when it becomes available.

A final determination surrounding the death of Resident #1 will be determined once the police report, any additional documents discovered and death certificate are reviewed.

Exit interview was conducted

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3