197609963-9-27-2024-29-AS-KHEN-D9LUQS-20240930154737

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609963
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:55:52 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
08/05/2024 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20240805121651

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:	12:22 PM
MET WITH:	Hector Gomez, Assistant Administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Staff did not prevent resident from being assaulted by another resident

INVESTIGATION FINDINGS:

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

On 8/13/24, Licensing Program Analyst (LPA) Christine Yee conducted an unannounced initial complaint visit to investigate the above allegation and met with Hector Gomez, Assistant Administrator. The reason for today's visit was explained. On the visit conducted on 8/13/24, LPA Yee conducted an interview with Hector Gomez, Assistant Administrator at 12:20pm, Resident #3 at 1:48pm, Resident #4 at 2:01pm, Resident #5 at 2:07pm, Resident #6 at 2:27pm, telephone interview with Staff #1 at 3:27pm and a partial telephone interview with Staff #2 at 3:02pm and an office interview at 3:51pm. A tour of the dining room was also conducted at 4:27pm. Based on the information obtained from interviews conducted on

Continued on LIC9099-C

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)

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Control Number 29-AS-20240805121651

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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the initial visit, it was determined that further investigation is needed to make a finding for the above allegations.

Based on the information obtained from interviews conducted, regarding the allegation that staff did not prevent resident from being assaulted by another resident, on 5/20/24 at around 5:30pm, the facility residents were in the dining room, including Resident #1 and Resident #2. Resident #2 attempted to seat at table assigned to residents who use wheelchairs. Resident was asked by staff to move as one of the residents who sat at the table was on the way to dinner. Resident #2 reluctantly got up, mumbling loudly and calling other residents names and using racial slurs. This caused Resident #1 to react to Resident #2. Loud words were exchanged between the two residents. Resident #2 even attempted to instigate a fight with Resident #1 outside, causing another resident to come to resident’s defense. Staff #1 was able to get in between Resident #1 and Resident #2. Per Staff, Resident #2 had their food and was asked to go to their room and they were in the process of complying. They changed their mind and without any warning, turned around and threw the hot bowl of soup on a plate at Resident #1. The hot soup ended up on Resident #1’s head. Per Staff #2, Resident #1 was yelling that staff was not doing anything. Staff offered to call 911 but Resident #1 insisted on making the call immediately from the dining room phone. Per Staff, they had Resident #1 behind the food counter just in case Resident #2 returned. Resident#1 was transported to the hospital by the paramedics before the arrival of the police. When the police arrived, they spoke with Staff #1 and arrested Resident #2. The police interviewed Resident #1 in the hospital and returned to interview Resident #3 and Resident #7.

continued on LIC9099-C

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)

Page: 2 of 3

Control Number 29-AS-20240805121651

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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A court hearing was scheduled on 8/13/24 regarding this incident and witnesses were subpoenaed. The staff does not have any information regarding the disposition of the case.

Based on the information obtained during the investigation, there is insufficient evidence to support the allegation that the staff did not prevent resident from being assaulted by another resident, 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: 09/27/2024

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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