<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609963
Report Date: 12/16/2024
Date Signed: 12/16/2024 03:56:19 PM

Document Has Been Signed on 12/16/2024 03:56 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/
DIRECTOR:		MARTY BACONFACILITY TYPE:
735
ADDRESS:6130 VINELAND AVETELEPHONE:
(818) 766-8161
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 58CENSUS: 49DATE:
12/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:07 AM
MET WITH:Hector Gomez, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 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 to investigate the circumstances surrounding the death of Resident #1. LPA Yee met with Hector Gomez, Assistant Administrator. Also participating in today's visit was Stephen Manalo, Staff. The reason for today's visit was explained.

On today's visit, LPA Yee obtained copies of Resident #1's file, interviewed the Assistant Administrator at 11:31am, Staff #1 11:15 am, Staff #2 at 1:18pm and Staff #3 at 1:40pm. Resident #1's bedroom was toured at 1:50pm.

Per information obtained, Resident #1 had spent the prior week with family and returned to the facility on the evening of 12/9/24 around 6:00 or 6:30pm and went to their room. Resident #1 had already had dinner with family. Resident #1 had returned with a new cell phone and went to the central desk to obtain a pass word to hook their phone to wi-fi. The staff working at the time did not know the password so Resident #1 went back to their room. Approximately an hour later, Resident #1 went back to central station and asked for another staff who was not scheduled to work that day. Resident #1, who is a smoker, was observed going in and out to smoke and finally went to bed around 10:30pm. Resident #1 was observed laying on their side during room check conducted at 3:30am and was again observed in bed when room check was conducted at 6am. At around 8:40 or 8:50am the housekeeper went to clean Resident #1's room. The housekeeper knocked on the door and when there was no response, the housekeeper entered the room. Resident #1 was observed laying horizontally across the bed, face down, with arms spread out and legs hanging off the bed. Staff tried to wake the resident and there was no response. Staff went to call the Assistant Administrator and they both returned to the room. Resident did not have a pulse and did not respond. 911 was contacted. The paramedics checked Resident #1's pulse and used a stethoscope on Resident #1's back and pronounced them deceased at 9:31am. The paramedics informed staff not to touch anything in the room and
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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 2
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: 12/16/2024
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
to keep everyone away from the room. Per information received through interviews, the following items were found next to Resident #1: a plastic bag that contained a white substance that looked like a sugar cube, a roll of aluminum foil, cell phone, deodorant and a wad of cash. The coroner also found a rolled up dollar bill and a lighter clenched in Resident #1's hand. The items found on the bed were taken by the Coroner. Resident #1 was transported to the Los Angeles County Morgue. Per the information given to the staff, Resident #1 died of a fentanyl overdose. Per review of Resident#1's file, the resident was diagnosed with Schizophrenia and mild depression. Resident#1 also has a history of substance abuse.

Per tour of Resident #1's room, there were no visually obvious health and safety issues. It is unknown where Resident #1 obtained the fentanyl.

The facility notified Resident #1' responsible staff/payee and placement agency. The family was billed for the December 2024 rent but they have not yet paid the rent. The facility will issue a credit memo for the days remaining after the resident deceased. The facility did not handle the residents money and the resident had no belongings that the family would have to pick up. LPA Yee requested that the facility provide the Department with a copy of the death certificate when it becomes available.


Exit interview was conducted.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2