197609963-9-20-2024-29-AS-CYEE-D9AUZ2-20240920160048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609963
Report Date: 09/20/2024
Date Signed: 09/20/2024 04:00:55 PM

Document Has Been Signed on 09/20/2024 04:00 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:	01:42 PM
MET WITH:	Hector Gomez, Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:15 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	Allegation: Neglect/Lack of Care and Supervision: Resident #1 (R1) was found hanging by their neck with a belt in R1’s bedroom closet. Licensing Program Analyst (LPA) Christine Yee conducted a subsequent case management visit to deliver findings for the above allegation. LPA Yee met with Hector Gomez, Assistant Administrator and explained the reason for the visit. On 05/19/2023, the Woodland Hills Adult and Senior Care Office (RO) received a Death Report (LIC624A form) from the facility for Resident #1 (R1). On 05/16/2023, R1 was found by Resident #2 (R2) hanging by their neck with a belt inside their bedroom closet. On 05/22/2203 the case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Olivia Spindola. On 05/23/2023, from 2:00pm to 3:25pm, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced health and safety visit as a result of the Death Report received for R1. LPA Yee met with Hector Gomez, Administrator Assistant and explained the reason for the visit. On 5/19/2023, the Department received an emailed copy of an LIC624A Death Report for R1. Per the information received, the circumstances surrounding the death of R1 on 5/16/2023 may be questionable and needed to be investigated to determine if the facility was in any way culpable for the death. Emergency services, law enforcement and the Coroner's office were called to the facility on the day of R1’s death. During the visit, the LPA conducted a tour of the facility, with emphasis on R1’s room and collected additional documents. The LPA did not visually observe any obvious or immediate danger with the physical plant during the visit. Residents in the designated smoking area were observed to be clean and looked well. The LPA determined 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

NARRATIVE

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further documents would need to be obtained and reviewed from the responding agencies noted above and further investigation was needed to conclusively determine any fault of the facility related to R1’s death.

On 06/05/2023, Investigator Spindola conducted an interview with the Assistant Administrator, and from approximately 1:30pm to 1:45pm, with residents; on 07/14/2023, at approximately 9:00am, with the Administrator; on 07/25/2023, from approximately 9:45am to 11:00am, with Administrator and Resident #2 (R2); and on 08/04/2023, at approximately 10:40am, with the County of Los Angeles Medical Examiner-Coroner’s (CLAMEC) office. In addition, the investigator reviewed the Los Angeles Police Department (LAPD) death investigation report, and facility file documents related to R1.

According to R1’s Physician Report completed on 12/14/2021, by Gateways Hospital and Mental Health CRTP, R1’s primary diagnosis was Schizoaffective. R1 was further described as ambulatory and requiring care for personal needs, such as medicine storage and medical supervision. There was no history of suicide ideation listed on the physician report, or the pre-appraisal form dated 09/08/2022.

The Department’s investigation revealed on 05/16/2023, R2 found R1 hanging by R1’s neck with a belt in their bedroom closet. The investigation revealed R1 hanged themself inside the closet using a belt that R1 tied around R1’s neck and secured it to the closet's rod. R1’s knees were bent, and the belt broke R1’s neck. Facility staff stated R1 never displayed signs of depression and suicidal ideation. They were not aware R1 had history of a suicide attempt prior to moving into the facility on 09/08/2022. The Los Angeles Police Department (LAPD) completed a Death Report, listing R1’s death as suicide. The LAPD report also noted that R1 had attempted suicide approximately one year ago and was placed on a hold. The County of Los Angeles Medical Examiner-Coroner (CLAMEC) investigation determined R1’s manner of death was suicide, and the cause of death was by hanging. Based on interviews with staff and witnesses, LAPD and CLAMEC's investigations and R1’s prior suicide attempt, the Department determined there was no neglect/lack of care and supervision by the facility which led to R1’s death. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview was conducted, copy of report given.

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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