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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609969
Report Date: 08/06/2024
Date Signed: 08/06/2024 05:38:41 PM


Document Has Been Signed on 08/06/2024 05:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:VALLEY VISTA SENIOR LIVINGFACILITY NUMBER:
197609969
ADMINISTRATOR:ELIZABETH J WHITTINGTONFACILITY TYPE:
740
ADDRESS:7040 VAN NUYS BLVDTELEPHONE:
(818) 906-4400
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:164CENSUS: 66DATE:
08/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Elizabeth Whittington, Executive DirectorTIME COMPLETED:
05:45 PM
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit to follow up on the incident where a memory care resident was able to leave the facility without staff's knowledge. LPA Yee met with Elizabeth Whittington, Executive Director. The reason for today's visit was provided.

On today's visit, interviews were conducted with the Administrator at 1:05pm, a telephone interview with a family member at 3:54pm, an attempted interview with Resident #1 at 2:49pm and tour of the Memory Care Unit at 2:40pm. Staff schedules and documents were also obtained from Resident #1's file from 1:05pm through 3:35pm.

Based on the information obtained on today's visit, it has been determined that further information is needed to make a determination if the facility took all necessary safety measures to ensure that Resident #1 was not able to leave the Memory Care Unit without Staff's knowledge.

Exit interview was conducted.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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