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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609963
Report Date: 04/03/2025
Date Signed: 04/04/2025 09:44:29 AM

Document Has Been Signed on 04/04/2025 09:44 AM - 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: 50DATE:
04/03/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Hector Gomez, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:25 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted a subsequent unannounced continuation Annual Inspection visit 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 5 domains of the CARE Inspection Tool were reviewed on today's visit: Personnel Records-Training, Clients Rights - Info, Health Related Services, Client Rec-Incident Report and Emergency Intervention. Also reviewed were 5 resident files and 5 staff files. The following domains will be reviewed on a return visit: Physical Plant, Incidental Medical Service and Disaster Preparedness.

The following deficiencies were observed during today's visit:
  • Per review of Client #4 and #5's file, the administrator was not able to provide completed PRN Authorization letters for the PRN medications being taken by both clients.
  • Staff #6's file did not have evidence of a physical with the results of a TB test.
  • Per review of the first aid kit, no first aid manual was observed.
  • Per the initial visit conducted on 3/19/25, the clients' meals are prepared off-site and it was
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/03/2025
NARRATIVE
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  • observed that the facility did not have an approved food waiver by the Department to have meals prepared off-site and brought in. The deficiency not previously addressed, is being addressed on today's visit.


Deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 1 and Chapter 6.

Exit interview was conducted, APPEALS RIGHTS were discussed and a copy given.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2025 09:44 AM - It Cannot Be Edited


Created By: Christine Yee On 04/03/2025 at 05:50 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: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(12)(A-C)
Food Services - (a) In facilities providing meals to clients, the following shall apply: (12) If food is prepared off the facility premises, the following shall apply: (A) The preparation source shall meet all applicable requirements for commercial food services. (B) The facility shall have the equipment and staff necessary to receive and serve the food and for cleanup.
(C) The facility shall maintain the equipment necessary for in-house preparation, or have an alternate source for food preparation, and service of food in emergencies.
This requirement was not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as the facility has a contract with the skilled nursing home located next door to have them prepare and cook all clients meals and snacks and then transported next door. However the facility does not have an approved food waiver from the Department, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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 The Licensee will submit a food waiver request to the Department to obtain a waiver to allow the preparation of food off-site and transported to the facility for client consumption by 4/17/25.
Type B
Section Cited
CCR
80075(b)(5)
80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met:
This requirement was not met as evidenced by:

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 as per review, Client #4 and Client #5 did not have completed PRN Authorization letters by their physician for their PRN medications noted on the March 2025 list of centrally stored medications, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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The Licensee will review all Client files to ensure that every client has a completed PRN Authorization Letter from the prescribing physician and maintained in each clients file by 4/17/25. Evidence will be provided to the Department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2025 09:44 AM - It Cannot Be Edited


Created By: Christine Yee On 04/03/2025 at 06:35 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: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
80066 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 per review of staff records, Staff #6 in 1 out of 5 staff files reviewed, did not have evidence of a physical with the results of a TB test, which poses/posed a potential health and safety risk or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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The Licensee will review all staff files to ensure that all staff have received a physical and a TB test prior to working at the facility or have them complete a physical with a TB test if one is needed by 4/17/25. Provide evidence that Staff #6 has submitted to a physical and a TB test by 4/17/25
Type B
Section Cited
CCR
80075(g)(1)(A)
80075 Health Related Services
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility. (1) The supplies shall include at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

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 iper review of the first aid kit, there were no first aid manuals iobserved which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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The Licensee will ensure that a first aid manual, approved by the American Red Cross, the American Medical Association or a state of federal health agency is purchased and maintained with the first aid kit by 4/4/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
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