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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609963
Report Date: 03/19/2025
Date Signed: 03/19/2025 05:41:52 PM

Document Has Been Signed on 03/19/2025 05:41 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: 51DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:28 AM
MET WITH:Hector Gomez, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted a required Annual Inspection using the complete CARE Inspection Tool and met with Hector Gomez, Assistant 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 (26 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.

The following domains of the CARE Inspection Tool were inspected on today's visit: Infection Control, Operational Requirements, Staffing and Food Service. Due to time constraints, the remaining domains will be reviewed on a return visit. A visit to the skilled nursing facility located next door was toured at 2:55pm to review the food supply.


Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 1 and 6.
Any deficiencies not cited on today's visit will be addressed on the return visit.

Exit interview was conducted, Appeals Rights discussed and a copy was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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Document Has Been Signed on 03/19/2025 05:41 PM - It Cannot Be Edited


Created By: Christine Yee On 03/19/2025 at 05:15 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: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(4)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (4) Between meal nourishment or snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation , the licensee did not comply with the section cited above in all counts. The facility had 6, 20 ounce cans of crackers in the storage closet and is insufficient to last 7 days for in between meal snacks which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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The licensee will purchase sufficient variety of snacks to allow for serving in between meals for 7 days by 3/20/25.
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in all counts as the facility does not maintain the required perishable foods for a minimum of 2days and non-perishable foods for a minimum of 7days on the premises as the facility has meals prepared and delivered from the facility located next door which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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The Licensee will purchase and maintain the required minimum 2 days of perishable and 7 days of non-perishable foods on site and provide a written plan as to how they will remain in compliance with Title 22 requirements by 3/20/25.
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: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


LIC809 (FAS) - (06/04)
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