197609969-3-25-2022-29-AS-SWAR-CCUQ7Z-20220325115558

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609969
Report Date: 03/25/2022
Date Signed: 03/25/2022 11:59:43 AM

Document Has Been Signed on 03/25/2022 11:59 AM - 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 LIVING		FACILITY NUMBER:	197609969
ADMINISTRATOR:	JOLIE HIGGINS		FACILITY TYPE:	740
ADDRESS:	7040 VAN NUYS BLVD		TELEPHONE:	(818) 906-4400
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	164	CENSUS: 45	DATE:	03/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Adrienne Craig-Aziz, Executive Director		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required annual visit at 9:15 a.m. This annual had a specific emphasis on infection control practices and procedures. Upon entry, the LPA met with Executive Director Adrienne Craig-Aziz, and explained the reason for the visit. The LPA toured the physical plant areas inside and outside, with Executive Director Adrienne Craig-Aziz at 9:50 a.m., to ensure there are no health and safety hazards. Kitchen: The kitchen area appeared clean and sanitary. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food in the refrigerator/freezer were properly labeled. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 119.2 degrees Fahrenheit at 10:05 a.m. Bedrooms: The LPA observed resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. Restrooms: Each private restroom is designed as a full restroom. The resident bathrooms and shower rooms are properly equipped with grab bars and shower rooms are equipped with non-skid material. Hot water was randomly tested throughout the facility inspection; temperature ranged between 113.4 and 116.1 degrees Fahrenheit. Common Areas: Fire extinguishers were observed throughout the facility, and were fully charged with a service date of 1/7/2022. The building is a five-level facility, which consists of offices, medication rooms, laundry rooms, multiple supply closets, beauty parlor, staff room, kitchen/dining room, fitness room, theater, and activity/lounge rooms. The LPA observed common areas, including furniture and activity equipment, to be clean and in good condition. Additional food storage rooms contain additional nonperishable, and perishable food items on the first level of the facility. Continue on LIC809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 197609969
	VISIT DATE: 03/25/2022

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. Medication room: First aid kit, medications, and medication records are kept in the medication room. The medication room(s) contain a separate dispenser for all sharps.
BACKYARD: The patio has covered outdoor areas equipped with furniture for resident use. There were no bodies of water noted.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Executive Director regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

Exit interview conducted, and a copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC809 (FAS) - (06/04)

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