197609963-5-23-2023-29-AS-CYEE-CS4U43-20230523151427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609963
Report Date: 05/23/2023
Date Signed: 05/23/2023 03:15:58 PM

Document Has Been Signed on 05/23/2023 03:15 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

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: 51	DATE:	05/23/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Hector Gomez, Administrator Assistant		TIME COMPLETED:	03:25 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 health and safety visit as a result of the Death Report received for Resident #1. LPA Yee met with Hector Gomez, Administrator Assistant and the reason for today's visit was explained. On 5/19/23, the Department received an emailed copy of an LIC624A Death Report for Resident #1. Per the information received, the circumstances surrounding the death of Resident #1 on 5/16//23 may be questionable and needs to be investigated to determine if the facility is 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 the Resident #1's death. On today's visit, LPA Yee conducted a tour of the facility, with emphasis on Resident #1's room and collected additional documents. LPA Yee did not visually observe any obvious or immediate danger with the physical plant on today's visit. Residents in the designated smoking area were observed to be clean and looked well. However, it was noted that the facility failed to report the death of Resident #1 to the Department by the next working day during its normal business hours as required by regulations. Documents will need to be obtained and reviewed from the responding agencies noted above and further continued on LIC809C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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 3

Document Has Been Signed on 05/23/2023 03:15 PM - It Cannot Be Edited

Created By: Christine Yee On 05/23/2023 at 12:39 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: 05/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/30/2023 Section Cited CCR 80061(b)(1)(A)	1 2 3 4 5 6 7	REPORTING REQUIREMENTS: Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report	1 2 3 4 5 6 7	The Licensee shall review Title 22, Section 80061 and 85061 and submit a signed statement stating that both Sections were read and that the facility will adhere to the reporting requirements by POC date - 5/30/23
	8 9 10 11 12 13 14	containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (A) Death of any client from any cause. Resident #1 deceased on 5/16/23 and was not reported to the Dept until 5/19/23	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Christine Yee

LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/23/2023

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

investigation would be needed to conclusively determine any fault of the facility related to Resident #1's death. LPA Yee will deliver the final report with the results of the investigation once it has been completed.

Citations were issued for late reporting under California Code of Regulations, Title 22, Division 6, Chapter 1.

Exit interview was conducted, Appeals Rights were discussed and a copy provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3