197609963-9-27-2024-29-AS-KHEN-D9LUL8-20240930154018

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609963
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:54:01 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
04/11/2024 and conducted by Evaluator Christine Yee

COMPLAINT CONTROL NUMBER: 29-AS-20240411082946

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:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	10:49 AM
MET WITH:	Hector Gomez, Assistant Administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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1. Drug activity on the premises
2. Staff did not ensure facility is free of cockroaches
3. Staff did not ensure facility is free of head lice

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Yee conducted a subsequent unannounced complaint visit to deliver findings for the above allegations. LPA Yee met with Hector Gomez and explained the reason for the visit.

On 04/11/2024, the Department received a complaint regarding an allegation of drug activity on the premises. It was alleged that neglect by the staff members led to the use of illegal drug use by the residents. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Dennis Douglas.

On 04/12/2024, from 9:30am to 3:00pm, Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced initial complaint visit to the facility. At 9:30am, LPA Conway met with the administrator Martha

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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-20240411082946

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: 09/27/2024

NARRATIVE

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Bacon and Assistant Administrator, Hector Gomez and explained the reason for the visit. At 10:15am, LPA Conway, along with the assistant administrator, conducted a brief physical plant tour. At 12:30pm, LPA Conway requested copies of pertinent documents. LPA Conway also conducted brief interviews with the Assistant Administrator and residents. LPA Conway informed the administrator and assistant administrator that the allegation would be referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Dennis Douglas for further investigation.

On 04/19/2024, at approximately 10:10am, Investigator Douglas conducted an interview with Resident #1 (R1). In addition, complaint documents including the Report of Suspected Dependent Adult/Elder Abuse (SOC341) form were also reviewed.

According to the information obtained during the Department’s investigation, R1 reported that some of the residents use drugs at the facility. R1 stated residents typically do the drugs in their rooms, or on the side of the building. R1 stated the facility staff members are aware of the illegal drug use at the facility. Staff members now check the residents’ rooms more frequently than they did in the past. However, the staff members still do not go through everything in the rooms when they are checking them. R1 stated the staff check the rooms approximately once a month and clean the rooms every day. R1 further stated the staff are now requiring the residents to take urine tests when they suspect they are using illegal drugs.

The information obtained during the Department’s investigation did not provide sufficient evidence to support the allegation. While some of the residents may have used drugs while in or out of the facility, there was no evidence that the staff neglected the residents, which led to the residents’ drug use. In addition, Investigator Douglas conducted a tour of the facility and did not observe any illegal drug use or drug paraphernalia. The investigator also did not observe anyone who appeared to be under the

continued on LIC9099

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240411082946

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: 09/27/2024

NARRATIVE

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influence of illegal drugs. Therefore, the allegation of “Neglect by the staff members led to illegal drug use by the residents” is deemed Unsubstantiated at this time.

Per interviews conducted with the Assistant Administrator on 9/20/24 regarding allegation #2 - staff did not ensure facility is free of cockroaches, he admits that sometimes a cockroach is seen in the facility. They retain a pest control company that comes in approximately 2 times a month to treat the facility as a preventative measure. Residents bring items in from the outside, have food items in their rooms which attract them. However, they are not aware of any cockroaches at this time. Resident #1 made the allegation because they did not want to pay the annual rent increase that went into effect in January 2024 for SSI recipients. A tour of the facility was conducted today at 11:42pm and random areas of the facility were visually inspected and there were no cockroaches observed. Based on the interviews conducted and tour of the facility, there was insufficient evidence to support the allegation that staff failed to ensure facility is free of cockroaches at this time, therefore the allegation is unsubstantiated.

Interviews were also conducted regarding allegation #3 – staff did not ensure facility is free of head lice and the information received from interviews conducted with the Assistant Administrator on 9/20/24, Resident #1 did not have head lice when they lived here. The facility has not had lice for about 2 years. Resident #2 was the last known resident who had head lice. It is unknown where the head lice were picked up. Resident #2’s conservator was notified, and the resident had all their hair shaved off. Since then, the resident would ask for a very short hair cut until they left on 6/6/24 due to declining health. Per the Assistant Administrator they are not aware of any resident having head lice at the facility. Based on the information obtained during the investigation, there is insufficient evidence to support the allegation that staff did not ensure facility is free of head lice 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: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

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