197609963-2-7-2023-29-AS-JAPL-CQ7NGT-20230323102736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609963
Report Date: 02/07/2023
Date Signed: 02/07/2023 11:58:17 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/01/2023 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230201094032

FACILITY NAME:	VALLEY MANOR GUEST HOME		FACILITY NUMBER:	197609963
ADMINISTRATOR:	MARTY BACON		FACILITY TYPE:	735
ADDRESS:	6130 VINELAND AVE		TELEPHONE:	(818) 766-8161
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	58	CENSUS: 49	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Martha Bacon, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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1. Staff are not providing medical information to resident's physician.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Christine Yee conducted an initial unannounced complaint visit and met with Martha Bacon, Administrator. Hector Gomez, Assistant Administrator also participated in the visit. The reason for today's visit was explained.

On today's visit , LPA Yee conducted face to face interviews with both Martha Bacon and Hector Gomez beginning at 8:41am, Staff #1 was interviewed at 9:29am and Witness #1 was interviewed at 10:05am via telephone. LPA attempted to interview Resident #1(R1) but resident was not on site. Facility documents were reviewed and copies of relevant documents were obtained.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230201094032

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY MANOR GUEST HOME	FACILITY NUMBER: 197609963
	VISIT DATE: 02/07/2023

NARRATIVE

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Per information received during the investigation for the above allegation, Resident #1 was hospitalized for psychiatric reasons on 2/1/23 at the request of the conservator. The conservator also obtained a doctor's order for Resident #1's hospitalization. The facility made transportation arrangements. Per interviews conducted, facility staff will send a copy of the medication list, LIC601 Identification and Emergency Information and a copy of conservator documents with the ambulance driver. In Resident #1's case, they also sent a copy of page one of the Appraisal/Needs and Services Plan at the request of the ambulance driver. The resident returned to the facility on 2/3/23 via ambulance. Per staff interviews conducted, the facility did not receive any calls from the hospital or any individual requesting additional information related to the care of Resident #1. Per staff, usually the nurse at the hospital will call for information, not a doctor. The requested documents will then be faxed to the hospital once it is confirmed that it is someone from the hospital that is calling to ensure that confidentiality is maintained. The facility did get calls from the hospital social worker about the release of the resident and transportation arrangements but no calls regarding the resident's care

Prior to today's visit, LPA Yee made a couple of attempts, via telephone and email, to reach the treating physician by name, to obtain information regarding Resident #1 and was informed by hospital staff that they did not have any one working at the hospital by the name provided to LPA Yee. Witness #1 was interviewed via telephone at 10:05am and was not able to recognize the treating physician who allegedly requested the medical information.

Based on the information received today, LPA Yee was not able to establish with 51 percent certainty that the facility failed to provide the requested medical information. Therefore, the above allegation is unsubstantiated.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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