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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609969
Report Date: 02/08/2022
Date Signed: 02/08/2022 02:53:43 PM

Document Has Been Signed on 02/08/2022 02:53 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VALLEY VISTA SENIOR LIVINGFACILITY NUMBER:
197609969
ADMINISTRATOR:JOLIE HIGGINSFACILITY TYPE:
740
ADDRESS:7040 VAN NUYS BLVDTELEPHONE:
(818) 906-4400
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 164CENSUS: 45DATE:
02/08/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Becca Black, Executive DirectorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Salia Walker and Ashley Smith arrived unannounced at 10:30 a.m. for a Case Management-COVID-19. The LPAs met with Executive Director Becca Black and Business Office Manager Angela Webb, and explained the reason for the visit.

On January 19, 2022, LPA Salia Walker received a Special Incident Report (SIR), alleging that a resident was hospitalized and diagnosed with COVID-19. After speaking with the Executive Director, it was confirmed that as of January 20, 2022, there were eight (8) staff and nineteen (19) residents positive for COVID-19. Furthermore, it was revealed that the first confirmed case was noted on January 5, 2022. Whereas the facility reported the cases to the local health department, the facility failed to report the positive cases to the Department of Social Services.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted. Today’s report, and appeal rights were issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/08/2022 02:53 PM - It Cannot Be Edited


Created By: Salia Walker On 02/08/2022 at 01:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: VALLEY VISTA SENIOR LIVING
FACILITY NUMBER: 197609969

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2022
Section Cited
CCR
87211(a)(2)

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87211(a)(2) Reporting Requirements (2) Occurrences, such as epidemic outbreaks.. which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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The Licensee has agreed to do the following:
1.Submit a Statement of Understanding, indicating how the facility will maintain compliance with Section 87211(a)(2). Submit Statement no later than 2/11/2022
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This requirement is not met as evidence by:
Based on interviews, the licensee did not comply with the section cited above, as the facility failed to report eight (8) staff and nineteen (19) residents positive for COVID to the licensing agency, which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2022


LIC809 (FAS) - (06/04)
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