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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609963
Report Date: 03/18/2024
Date Signed: 03/18/2024 04:04:19 PM

Document Has Been Signed on 03/18/2024 04:04 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 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: 55DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Marty Bacon, AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analysts(LPAs) Christine Yee and Emily Peraldi conducted a joint required Annual Inspection using the complete CARE Inspection Tool and met with Marty Bacon, Administrator. Also participating in today's visit was Stephen Manalo, Administrative Assistant. The reason for today's visit was explained.

The facility is a 2 story, large commercial building consisting of bedrooms number 100-125 (25 rooms) downstairs and bedrooms #201-203(3 rooms) upstairs, dining room, 2 common shower rooms and 2 half bathrooms downstairs and 1 full bathroom and a half bathroom upstairs. The facility is fire cleared for 58 NON-AMBULATORY residents.

On today's visit, 8 staff files and 11 resident files were reviewed. The following 2 domains were also reviewed during today's visit: Personnel Records - Training, Client Rights - Information. The remaining 10 domains will be reviewed on a return visit.

Per review of resident files, 10 out of 11 resident files require an updated addendum to the Admission Agreement to reflect the change in the annual basic services rate, 6 out of 11 resident files did not have consent forms, 3 out of 11 files did not have completed Safeguards/Property Valuables, Resident #1 did not have evidence of a TB test, Resident #2 and Resident #3's Physician's Report does not indicate their ambulatory status. Per review of staff files, Staff #1 does not have evidence of first aid training, Staff #2 does not have a completed and signed Health Screening(LIC503).

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 1 and Chapter 6. Any deficiencies noted and not addressed on today's visit will be addressed on a return visit.
Exit Interview was conducted.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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
Document Has Been Signed on 03/18/2024 04:04 PM - It Cannot Be Edited


Created By: Christine Yee On 03/18/2024 at 03:19 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: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 8 staff files reviewed, Staff #2 does not have a completed and signed Health Screen(LIC503) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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The Licensee will review all staff files ensure that all staff have submitted to a health screen with the results of the TB test and maintain the documents in the staff's file. Provide evidence that Staff #2 has obtained a completed health screen by 3/25/24.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 8 files reviewed, Staff #1, does not have evidence of receiving first aid training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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The Licensee will review all staff files to ensure that all staff have received first aid training and evidence is maintained in their files. Licensee will provide evidence that Staff #1 has completed first aid training by 3/25/24.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/18/2024 04:04 PM - It Cannot Be Edited


Created By: Christine Yee On 03/18/2024 at 03:20 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: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1537.1(a)
Regulations
(a) A licensee of a residential facility serving adults that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for client use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above per information provided, the facility does not have a computer/internet access device designated for client use or usage policy which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Licensee will ensure that a internet access device that meets Title 22 requirement is made available for client use and a written usage policy is put in place to ensure that all residents have access to the computer within reasonable hours by 3/25/24
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024


LIC809 (FAS) - (06/04)
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