197609969-3-25-2021-29-AS-JAPL-BZKW2U-20210329165454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609969
Report Date: 03/25/2021
Date Signed: 03/25/2021 04:17:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/16/2021 and conducted by Evaluator Aja Richardson

COMPLAINT CONTROL NUMBER: 29-AS-20210316112148

FACILITY NAME:	VALLEY VISTA SENIOR LIVING		FACILITY NUMBER:	197609969
ADMINISTRATOR:	KEVAN SIDNEY		FACILITY TYPE:	740
ADDRESS:	7040 VAN NUYS BLVD		TELEPHONE:	(818) 906-4400
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	164	CENSUS: 34	DATE:	03/25/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Kevan Sydney		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility did not provide resident's authorized representative a copy of the resident's records in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Aja RIchardson initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with the Administrator Kevan Sydney.
Regarding the above allegation there are concerns that an attorney's office representing Resident #1 (R1) requested records from facility on 3/10/2021 and did not receive requested documents. To investigate this allegation LPA conducted interiew with R1's attorney on 3/16/2021 at 10 am and on 3/25/2021 LPA spoke with the facility Administrator. On 3/25/2021 LPA also reviewed initial record request and the email correspondence between the Administrator and facility attorney's office. According to the the interview and record review, the request was received on 3/16/2021, submitted to facility attorney's office for review on 3/18/2021. R1's attorney office has received notifaction that the documentation has been mailed to their office and the matter has been handled timely. At this time this allegation is Unsubstantiated. Report emailed to Administrator for signature.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

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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