197609963-3-26-2026-29-AS-CYEE-DSJ5GU-20260325195719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609963
Report Date: 03/25/2026
Date Signed: 03/26/2026 08:09:44 AM

Document Has Been Signed on 03/26/2026 08:09 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 HOME		FACILITY NUMBER:	197609963
ADMINISTRATOR/ DIRECTOR:	MARTY BACON		FACILITY TYPE:	735
ADDRESS:	6130 VINELAND AVE		TELEPHONE:	(818) 766-8161
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 58		CENSUS: 54	DATE:	03/25/2026
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:19 AM
MET WITH:	Hector Gomez, Administrator		TIME VISIT/ INSPECTION COMPLETED:	08:05 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 a subsequent unannounced required Annual continuation visit and met with Hector Gomez, Administrator. Also participating in today's visit was Stephen Manalo, Administrative Assistant. The reason for today's visit was provided. The following domains of the CARE Inspection Tool was reviewed on today's visit: Infection Control, Physical Plant & Environmental Safety, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness. The common areas and the following resident rooms were inspected together with Stephen. Manalo: Room #102, Room #107, Room #110, Room #115, Room #122, Room #00. LPA attempted to inspect room #119 but was refused entry by the resident. The emergency food supply stored on the premises and at the skilled nursing facility was inspected during today's visit. The following was observed during today's visit: all 6 resident rooms inspected are shared rooms and are furnished with 2 beds, 2 chairs, 3 wall lights - one over each bed and one in the center, a night stand, a chest of drawers/shared dresser, and a built in closet, The following deficiencies were also observed in the 6 bedrooms inspected: Room #102 - the center wall light in bedroom was not operational. Room #107 - one of the wall lamp was not operational, the window blinds were missing slats and the chest of drawers were broken. The water temperature tested in the bathroom read 122.5 degrees Fahrenheit.. continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

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 7

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)

Page: 2 of 7

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: 03/25/2026

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

Page 2.

The common bathroom identified as B1 (adjacent to the central desk) has 2 shower stalls with slip resistant mats. The water tested 92.7 degrees Fahrenheit.
The second common bathroom identified as B2 also has 2 shower stalls with slip resistant mats. The water temperature tested 109 degrees Fahrenheit.
Bedroom #110 was observed with 2 broken dressers, 1 chair only and cracking ceiling
One of the washers in the laundry room is not operating correctly and is pending replacement. The request was submitted on 3/18/26 and won't be repaired/delivered until 3/31/26.
Room #115 has a broken chest of drawer, one chair only and the water temperature tested 122.4 degrees Fahrenheit.
The only room with window bars is the office used by Anne Sippi and it pre-dates 1991.
Room #119 was not inspected as the resident refused entry
Room #122 the left and middle wall lamp was not operational, dresser drawer is broken, faucet knob is loose. The water temperature in the bathroom tested 96.7 degrees Fahrenheit.
Room #00 was observed with only one chair.
The smoke detectors were individually tested in each of the rooms inspected and were operational.
The carbon monoxide detectors all located in the hallway by: activity patio, room 105, room #124, room #112 and office window were all tested individually and was operational.
The facility has 5 fire extinguishers located in the following areas: back door to smoking area, Medication Room, hall bathroom assigned to Room 00, front of office door and Room 110 were all serviced on 10/15/25.
The facility's fire sprinkler system was last inspected by their vendor on March 23,2026 and no issues were observed per inspection report.
The window blinds in the front lounge is missing slats.
The centrally stored medications were secured in the medication room
First Aid kit and first aid manual was observed.
The outside area used for smoking has tables, chairs and sun block shade. The dumpster located in the parking lot was observed tightly closed. The outside areas were observed to be clean.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 6.

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

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 03/26/2026 08:09 AM - It Cannot Be Edited

Created By: Christine Yee On 03/25/2026 at 07:04 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: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the water temperature tested in rooms #102, #107, #110, 115, #122, #00, and the 2 common bathrooms-B1 and B2 read in order of the list - 103.4, 122.5, 110.1, 122.4, 96.7, 130.3, 92.7 and 109.0 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/26/2026
	Plan of Correction
1 2 3 4	The Licensee will test the water temperature in all resident bathrooms and adjust the thermostat to ensure that the hot water deliivered to fixtures used by clients to attain a water temperature of not less than 105 degrees Fahrenheit and not more than 120 degrees Fahrenheit by 3/26/26

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 03/26/2026 08:09 AM - It Cannot Be Edited

Created By: Christine Yee On 03/25/2026 at 07:04 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: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(d)

Fixtures, Furniture, Equipment, and Supplies

(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the rooms inspected - 102, #107, #122, it was observed that the light fixture above the beds were not working which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/01/2026
	Plan of Correction
1 2 3 4	Licensee will inspect all the wall lights in all the resident rooms to ensure that the wall lighting used in lieu of a lamp is in working condition by 4/1/26. Submit evidence of correction by 4/1/26

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

LIC809 (FAS) - (06/04)

Page: 5 of 7