197609963-9-20-2024-29-AS-KHEN-D9HT88-20240927142955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609963
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:50:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
04/21/2023 and conducted by Evaluator Christine Yee

COMPLAINT CONTROL NUMBER: 29-AS-20230421085946

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: 53	DATE:	09/20/2024
		UNANNOUNCED	TIME BEGAN:	10:39 AM
MET WITH:	Hector Gomez, Assistant Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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1. Facility staff provided false statements to licensing
2. Staff did not follow admission agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Yee conducted a subsequent unannounced complaint visit to conduct further investigations and to deliver the findings of the above allegations. LPA Yee met with Hector Gomez, Assistant Administrator. The reason for today's visit was explained.

On 4/25/23, LPA Yee conducted joint interviews with Marty Bacon, Administrator, at 1:21pm, Hector Gomez, Back-up Administrator at 1:33pm and reviewed and obtained copies of facility records for Resident #1 at 2:05pm. Due to time constraints, it was determined that further investigation is needed to make a finding for the above allegations. Exit interview was conducted with Marty Bacon.

On 8/30/24, telephone interviews were conducted with the Assistant Administrator at 2:46pm and Staff #1 at 4:24pm.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 29-AS-20230421085946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/20/2024

NARRATIVE

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On today's visit, LPA Yee conducted an interview with the Assistant Administrator at 11:18am to clarify information provided on the initial visit conducted on 4/25/24. Per information received from interviews conducted regarding allegation #1 - facility staff provided false statements to licensing - the complainant states that staff gave LPA Yee the incorrect time for when the family member contacted the facility to notify them of the death of Resident #1 as a result of a fatal automobile accident that occurred on the street about 150 feet from the facility on 3/10/23. LPA Yee was notified of Resident #1's death by Martha Bacon, Administrator on 3/13/23 and a case management visit was conducted on 3/14/23 to investigate the death of Resident #1. The main purpose of the case management visit was to determine if the facility contributed in any way to the death of Resident #1 by their failure to provide the appropriate care and supervision. A report was generated to document the visit and the information obtained from interviews conducted. Per information obtained from the interviews conducted on 3/14/23, the report indicated that "The identity of the accident victim was not revealed to the facility staff until 3/11/23, around 4pm by a family member." Per interviews conducted with staff, the timeline of when the facility found out the identity of the accident victim or when the call from family was received was approximated based on staff's best recollection of the activities that were going on at the time staff received the call from family member. During the interviews conducted, LPA Yee was aware that Staff provided information as they remembered it and it was not intended to deceive the Department. Staff #1 did not state with absolute certainty that the time was 4pm, just that it was around dinner time and that they were setting up. Staff did not anticipate that they had to remember the exact time of the call. Time was noted to establish that the call was received in the afternoon. Staff also recollects during the interview that the caller also enquired about a rent refund and that they were referred to the Administrator. The family member denies having requested a refund or discussing the matter. Each party remembers the telephone conversation differently and told to LPA Yee as they recall the conversation. Per interview with the Assistant Administrator, any refunds of rent would only be discussed with Resident #1's responsible person or Conservator. Based on the information received from interviews conducted, there is insufficient evidence to support the allegation that facility staff provided false statements to Licensing. Therefore, the allegation is unsubstantiated at this time.

Per interviews conducted and review of facility files regarding allegation - staff did not follow Admission Agreement - it is alleged that the facility did not adhere to it's own rule under (4) Monitoring and Supervision c. Leaving the Facility: As you leave the facility, there is a sign-out book. For safety reasons, residents must sign out and back in upon return at the front lobby, page 19 of the Admissions Agreement.

continued on LIC9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230421085946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/20/2024

NARRATIVE

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Resident #1 ate breakfast on the morning of 3/10/23 around 7:45 or 8am and returned to their room. Around 8:45 or 9am, Resident #1, was observed leaving the facility. Resident #1 knows they have to sign out. Failure to sign in or out is not justification for the facility to violate a resident’s personal right to come and go from the facility. The facility is not a locked facility. Per review of Resident #1's file, resident has been determined by their physician to be able to leave the facility without assistance. Per interview with the Assistant Administrator, staff remind residents to sign in and sign out. Most residents are compliant but there are some that don't sign in or out at all, even when reminded. Staff usually know those residents' pattern. For example, Staff know that Resident #2 does not sign in or out, but their parent will notify the facility when the resident goes home to visit. Resident #1 likes to go in and out of the facility all day. When Resident #1 left the facility on 3/10/23 they were not considered missing and no notification to the family was made. The facility did not have any reason to believe that Resident #1 was involved in the accident, just that he was not on the premises.

Per interviews conducted with staff, the residents and a staff who lives in the area made the facility staff aware that someone was hit by a vehicle outside the facility. The accident area had been sealed off and no one knew the identity of the person who was hit. Facility staff had done a head count of the residents and determined that 2 residents were not on site. Room checks are done every 2 hours. Staff knew that one resident was visiting with family that lived close to the facility. Resident #1 was the only one unaccounted for. Around 10:30am a resident brought a policeman to the office. The officer spoke with the Administrator, and he was advised that only one facility resident was unaccounted for. A request was made by the Administrator to the officer to let her know if the victim was a resident of the facility. The officer took a copy of a picture of Resident #1 with his cell phone camera and left. The officer did not reveal the identity of the accident victim during the office visit and did return to provide the identity of the victim. The officer informed the Administrator that the Coroner's office is responsible for notifying the victim's family. When Resident #1 did not come home that day, there was no reason to believe that the resident was the accident victim. Resident #1 always goes in and out of the facility all day long. When resident still did not come home the next day.

Continued on LIC9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 29-AS-20230421085946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/20/2024

NARRATIVE

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Staff were in the process of filing a missing person report when the family called to let staff know about the death of Resident #1. Staff #1 was stunned since they were not aware of the automobile accident that occurred outside the facility, the previous day.

Per interviews conducted and file review, there is insufficient evidence to support the allegation that staff did not follow Admission Agreement. Therefore, the allegation is unsubstantiated at this time.

No deficiencies were cited on today's visit.

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

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

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