197609963-6-20-2023-29-AS-JAPL-CU9NTD-20230731104433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609963
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:53:21 PM

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
06/15/2023 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230615145944

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: 54	DATE:	06/20/2023
		UNANNOUNCED	TIME BEGAN:	12:43 PM
MET WITH:	Martha Bacon, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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1. Staff do not ensure residents are provided with clean linen.
2. Staff do not ensure resident’s needs are being met.
3. Staff do not maintain clean showers for resident use.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegations and met with Martha Bacon, Administrator. LPA Yee explained the reason for today's visit.

On today's visit, LPA Yee conducted interviews with Martha Bacon, Administrator, at 12:48pm and then jointly with Hector Gomez, Assistant Administrator at 12:52pm and attempted to interview Resident #1 at 2:22pm. The 2 common bathrooms were toured at 2:10pm and resident room #s: 103, 105 and 107and 120 were toured at 3:04pm

Per interviews conducted with the Administrator and Assistant Administrator regarding allegation #1 -staff do not ensure residents are provided with clean linens, bed linens are changed once a week or more often if the linens get soiled. Linens are changed daily in increments of every seven rooms by staff. Per tour

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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-20230615145944

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: 06/20/2023

NARRATIVE

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conducted of Resident room # 103, 105, 107 and 120, the bed linens were observed to be well used but were observed to be clean. Staff have access to the linen closet and are able to change the linens if a resident has an accident or if the linen gets soiled. Per tour of the linen closet, extra blankets, towels, fitted and flat sheets and comforters were observed..

Per information obtained through interviews conducted with the Administrator and Assistant Administrator regarding allegation #2 -Staff do not ensure resident’s needs are being met. Resident#1 just recently moved into the facility. Resident #1 is very demanding, aggressive and abusive with staff and other facility residents. Resident #1 refuses assistance with bathing and refuses to bathe because the facility towels don't belong to the resident. Resident #1 also demands that the facility provide ice for the resident's use. The facility does not have ice service and only has ice when the skilled nursing facility sends over milk on ice for breakfast and later in the afternoon. Staff will provide Resident #1 with ice if there is ice available after meals are served. Resident#1 was observed with ice in a container on today's visit. Resident #1 has a bipolar diagnosis and has good days and bad days and depending on the day accuses the staff of stealing items or not providing services.

Per interviews conducted with the Administrator and Assistant Administrator, regarding allegation #3 -Staff do not maintain clean showers for resident use, the bathrooms are cleaned and bleached every morning. The bathrooms are also cleaned by staff as needed. Per tour of the 2 common bathrooms, the bathrooms were observed to be clean but old and well used. The glaze in the bath tub located in Shower #2 is old and has a yellow tinge to the glaze is in the process of being removed.

Based on the information obtained on today's visit, LPA Yee was unable to conclusively establish that the showers and bed linens were dirty and that the facility was not meeting the resident's needs, therefore the above allegations are unsubstantiated.

Exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

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