197609963-2-3-2025-29-AS-KHEN-DF4PC2-20250325111114

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609963
Report Date: 02/03/2025
Date Signed: 02/03/2025 05:29:45 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
01/24/2025 and conducted by Evaluator Christine Yee

COMPLAINT CONTROL NUMBER: 29-AS-20250124162919

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:	02/03/2025
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Hector Gomez, Assistant Administrator		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

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1. Staff did not provide proper supervision to resident
2. Staff are not providing a comfortable environment for resident
3. Staff threatened resident

INVESTIGATION FINDINGS:

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

On today's visit LPA Yee conducted an interview with the Assistant Administrator at 11:40am and Resident #3 at 12:03pm and reviewed and obtained copies of facility files during the visit. Resident #1 coultd not be interviewed as he has been missing from the facility since 1/31/25.

Per interviews conducted with the Assistant Administrator, he observed Resident #1 in the common area located by the dining room, wearing Resident #2's New York Nick's t-shirt. He asked Resident#1 to stop wearing Resident #2's clothes. Resident #2 has been away receiving medical services at a skilled nursing facility for over a month. Resident #1 responded very loudly and repeatedly to the Assistant Administrator

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

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-20250124162919

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: 02/03/2025

NARRATIVE

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, that he did not understand why he was wearing Resident #2's t-shirt. According to Resident #1, he was wearing Resident #2's t-shirt because Resident #2 was fornicating with their sister and daughter. Per the Assistant Administrator, Resident#1 does not have sister or a daughter. Per the Assistant Administrator, he repeated to Resident #1, using the same vulgar language that was being used by Resident #1 that no one was fornicating with their sister or daughter. He did not cuss at Resident #1 or use the F word to intimidate Resident #1. Resident #1 removed Resident #2's t-shirt as requested by the Assistant Administrator. Staff reviewed Resident #2's clothing stored in the room cupboard and they had all been worn by Resident #1. Staff removed Resident #2's clothing for washing and is currently stored in the linen closet for safekeeping.

Per interview conducted with Resident #3 at 12:03pm, he remembers the incident last week regarding Resident #1 wearing Resident #2's clothing. His room is close to the dining room and across from the central desk. Resident #1 likes to act out. Resident #3 confirmed that Hector did not use any foul or vulgar language with Resident #1. Resident #1 likes to cuss and was using the F word. Hector was gently explaining to Resident #1 why he should not be wearing Resident #2's clothes.

Based on the interviews conducted, there is insufficient evidence to support the allegations that 1. Staff made inappropriate comments towards resident, 2. Staff are not providing a comfortable environment for resident and 3. Staff threatened resident, therefore allegations are 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: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

LIC9099 (FAS) - (06/04)

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