197609963-9-20-2024-29-AS-CYEE-D9AUXT-20240920155852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609963
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:59:07 PM

Document Has Been Signed on 09/20/2024 03:59 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 HOME		FACILITY NUMBER:	197609963
ADMINISTRATOR/ DIRECTOR:	MARTY BACON		FACILITY TYPE:	735
ADDRESS:	6130 VINELAND AVE		TELEPHONE:	(818) 766-8161
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 58		CENSUS: 53	DATE:	09/20/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:22 PM
MET WITH:	Hector Gomez, Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced case management visit to deliver the findings of the investigation conducted for the death of Resident #1 and met with Hector Gomez, Assistant Administrator. The reason for today’s visit was provided.

On the morning of 3/13/23, LPA Yee received a telephone call from Marty Bacon, Administrator, advising her of the death of Resident #1 and a Death Report was faxed over later in the day. Resident #1 had been involved in a fatal automobile accident.

An initial case management visit to the facility was conducted on 3/14/23 to obtain information about the circumstances surrounding the death of Resident #1 and to determine if the facility had neglected to provide the appropriate care and supervision to the resident, resulting in the fatal accident. During the initial visit, interviews were conducted with Marty Bacon, Administrator, at 12:18pm, Hector Gomez, Assistant Administrator at 1:31pm, and Staff #1 at 1:53pm. LPA also toured the site of the automobile accident at 11:54am and reviewed Resident #1’s file at 2:10pm to determine if the resident is able to leave the facility unassisted. Per review of facility documents, Resident #1 has a primary diagnosis of Schizophrenia and is conserved. An attempt was also made to interview Resident #1’s roommate to obtain information about anything unusual that may have been observed about Resident #1 on 3/10/23 and was unsuccessful. The roommate was sleeping during the visit. LPA was also advised by staff that the roommate would not be a credible witness to Resident #1’s state of mind on the morning of the accident.

Per information received from interviews conducted with staff on the initial visit, Resident #1 was observed behaving like normal self on 3/10/23. Resident #1 had breakfast, listened to loud music, smoked, did not complain of any health issues and did not exhibit any suicidal ideations prior to leaving the facility and before being involved in the fatal accident. Per review of Resident #1’s Physician’s Report, the resident is able to

continued on LIC809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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

LIC809 (FAS) - (06/04)

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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY MANOR GUEST HOME	FACILITY NUMBER: 197609963
	VISIT DATE: 09/20/2024

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leave the facility unassisted. The Administrator was asked to request a copy of the police report and death certificate from the family to assist with the investigation.

During the investigation, LPA Yee also contacted the police department and the coroner’s office to obtain a copy of the police report and the coroner’s Medical Report. Due to the paper backlog in the Coroner’s office, a report would not be available for 4-8 months. An assignment request was sent to the Department’s Investigation Bureau to obtain the needed documents for review before a decision could be made if there was any neglect on the part of the facility. Per review of the reports obtained from the police department, a witness to the accident observed Resident #1 crossing the street wearing a hooded sweatshirt, with the hood on since it was a rainy day. The driver of the vehicle that collided with Resident #1 states that the resident suddenly appeared in front of the vehicle, and they could not stop in time to prevent the collision. The force of the collision propelled the resident in a north bound direction before colliding with the ground. The driver who went to provide aid also notes that the hood tied around Resident #1’s face had to be untied to check for breathing. Per email received from the police, they have determined the accident to be a non-criminal collision and no charges will be filed against the driver of the vehicle. Per review of the Coroner’s Medical Report and the official Death Certificate the immediate cause of death is multiple blunt traumatic injuries.

Per the investigation, it was determined that Resident #1 was able to leave the facility unassisted and therefore the facility was not required to ensure that Resident #1 was supervised while they were out in the community. Therefore, there is insufficient evidence to establish that the facility neglected to provide the appropriate care and supervision to the resident, resulting in the fatal accident.

No deficiencies were cited on this visit.

Exit interview was conducted and a copy of report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

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