197609963-6-27-2023-29-AS-JAPL-CUA5EH-20230731195335

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609963
Report Date: 06/27/2023
Date Signed: 06/27/2023 02:26:00 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
06/22/2023 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230622090012

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:	06/27/2023
		UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Marty Bacon, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff did not safeguard resident's personal belongings.

INVESTIGATION FINDINGS:

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

LPA Yee conducted interviews with Martha Bacon at 9:17am, Hector Gomez at 9:41am and Resident #2 at 9:57am. Resident #1 has been hospitalized and could not be interviewed. Resident #1's file was reviewed at 10:20am.

The investigation regarding the allegation that faciity staff did not safeguard resident's personal belongings revealed the following: Resident #1 moved into the facility in early June and all the resident's belongings were dropped off in the facility parking lot and moved into the resident's room and is not currently noted as missing. Resident #1 accused Hector of stealing resident's cigars, milk and other food items. Resident #1

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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-20230622090012

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: 06/27/2023

NARRATIVE

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also accused Hector of harassment, threats and rape and called the police on 6/15/23. Per information obtained from interviews regarding the facility's failure to safeguard Resident #1's personal belonging, Hector Gomez was assisting Resident #1 with breakfast and had gone to the residents refrigerator to get the Silk milk that the resident uses for cereal. The resident's refrigerator is locked to protect resident's food items. While Hector was at the refrigerator, Resident #2 also requested their Silk milk that was also stored in the same refrigerator. When Resident #1 observed this, accused both Hector and Resident #2 of stealing resident's milk. Resident #1 initially stated that he/she had 4 individual quarts of Silk milk. Per Hector, he pointed out that there were 4 additional quarts of milks in the refrigerator, and the one that Resident #2 had was not one of the 4. Resident #1 than stated that he/she had five and then 6 individual quarts of Silk milk. Per Hector, he told Resident #1 that Resident #2's milk had their name on the milk carton and this pacified Resident #1. Resident #2 confirmed that this incident happened about 2 weeks ago.
There was another incident where Resident #1 accused Hector of stealing resident's sausages and was going around telling all the residents about the missing sausages Per Hector, he did not take or steal the sausages. He went and purchased the same sausages that were allegedly stolen to keep Resident #1 happy. Per Resident #2, he/she also purchased sausages for Resident #1. Per Hector, he is also accused of taking 1 package out of 5 packages of cashews from Resident #1. Per Hector, Resident #1 probably finished eating a package of cashew. Resident #1 also alleges that the staff are going through the resident's purse and took a cigar. This accusation stems from an incident that occurred in the area designated for smoking. Resident #1 eats all meals outside and had requested a fork from Hector. Hector brought a spoon and fork but observed a spoon and fork already in Resident #1's opened purse. Hector told resident that he wouldn't leave the ones he brought over since Resident #1 already had one. Resident #1 accused Hector of going through resident's purse and stealing.

On 6/23/23, Resident #1 who has a medical and psychiatric diagnosis, had refused medications for 2 days, had a behavioral episode and was hospitalized. Based on information provided by the hospital, it is unknown when Resident #1 will be able to return to the facility. Resident #1's belonging have been inventoried, packed up and stored in the basement for safe keeping. Based on the information obtained on today's visit, the above allegation is deemed to be unsubstantiated.

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

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC9099 (FAS) - (06/04)

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