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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609963
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:56:21 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS 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
05/06/2024 and conducted by Evaluator Christine Yee
COMPLAINT CONTROL NUMBER: 29-AS-20240506084116
FACILITY NAME:VALLEY MANOR GUEST HOMEFACILITY NUMBER:
197609963
ADMINISTRATOR:MARTY BACONFACILITY TYPE:
735
ADDRESS:6130 VINELAND AVETELEPHONE:
(818) 766-8161
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:58CENSUS: 53DATE:
09/20/2024
UNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Hector Gomez, Assistant AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not provide an eviction notice to client or client's authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Yee conducted a subsequent unannounced complaint visit to deliver the findings for the above allegations and met with Hector Gomez, Assistant Administrator and the reason for the visit was explained.

On 5/14/24, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced initial complaint visit to investigate the above allegation and met with Marty Bacon, Administrator and Hector Gomez, Assistant Administrator. The reason for today's visit was explained.

On the visit conducted on 5/14/24, LPA Yee reviewed and obtained copies of Resident #1's file, interviewed Hector Gomez, Assistant Administrator at 2:52pm and attempted to interview Resident #1 at 3:54pm but was not successful. Per Resident #1, it was not convenient to conduct an interview today.

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 3
Control Number 29-AS-20240506084116
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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Per information obtained on the visit, further investigation is needed to make a finding for the above allegation. Exit interview was conducted.

0n 9/11/24, telephone interviews were conducted with Hector Gomez, Assistant Administrator at 3:22pm to clarify information received during the initial complaint visit and Staff #1 at 4:16pm. LPA Yee was not able to interview Resident #1 as the resident was relocated by their placement agency after a hospital stay.

Per information obtained during the investigation regarding the allegation that staff did not provide an eviction notice to client or client’s authorized representative. The investigation revealed that Resident #1 was given a 30 day Eviction Notice on 1/12/24. Resident #1 was being evicted for verbal and physical abuse towards staff and residents, non-compliance with physician’s orders and medications and poor hygiene. The Department was provided with a copy of the eviction notice via email on 2/6/24 by the Assistant Administrator. Per review of the 30 day Eviction Notice, a return email response was sent to rescind the eviction notice since the basis for the eviction was invalid. Also, the notice did not provide itemized dates of violations, list of violations, resources provided, witnesses and evidence of a reassessment. As a result of the rescission, the eviction notice was voided and not enforced.

Resident #1 continued to reside at the facility and their behaviors escalated. Resident #1 continued to verbally and physically threaten the staff and residents, scream and disrupt the other residents with their violent behaviors, instigate fights, hoarding, refusing medications and bathing. Each time the behavior incidents occurred, it would be reported to the case manager of Resident #1’s placement agency and the PET team called out to assess the resident for hospitalization. The first 8 times that the PET Team was called, they determined that Resident #1 did not meet criteria for hospitalization. The facility continued to work and communicate with the placement agency to find a relocation site for Resident #1. The placement agency was always aware that the facility wanted to evict Resident #1. In May 2024, the facility advised the placement agency that they were going to start the eviction process to evict Resident #1 once the Department reviewed and approved the 30 day Eviction Notice. Per information obtained, the placement agency believed that the facility was enforcing the original 30 day eviction given to the resident on 1/12/24 and is not aware of a second 30 day Eviction Notice. A second 30 day Eviction Notice was emailed to the Department on 5/10/24 for review and determined to be invalid also. The Administrator was contacted via telephone to rescind the notice and it was never given to Resident #1 or the placement agency.

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: 2 of 3
Control Number 29-AS-20240506084116
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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When the complaint was received on 5/6/24, there were no active evictions against Resident #1 and therefore there was no need to notify Resident #1 or the placement agency. Per interviews also conducted with facility staff, no one mentioned that the locks were going to be changed on Resident #1’s bedroom door as part of the eviction process. Per staff, they don’t do that. The suggestion was made by a placement agency staff.

Based on the investigation conducted, there is insufficient evidence to support the allegation that the staff did not provide an eviction notice to client or to client’s authorized representative.

No deficiencies were cited on today's visit.

Exit interview was conducted and a copy 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)
Page: 3 of 3