197609969-2-7-2024-29-AS-CYEE-D292WV-20240207164609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609969
Report Date: 02/07/2024
Date Signed: 02/07/2024 04:46:21 PM

Document Has Been Signed on 02/07/2024 04:46 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 LIVING		FACILITY NUMBER:	197609969
ADMINISTRATOR:	ELIZABETH J WHITTINGTON		FACILITY TYPE:	740
ADDRESS:	7040 VAN NUYS BLVD		TELEPHONE:	(818) 906-4400
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	164	CENSUS: 69	DATE:	02/07/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Elizabeth Whittington, Executive Director		TIME COMPLETED:	04:50 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) Christine Yee conducted an unannounced case management visit due to three incidents reported to the Department involving 2 alleged staff abuse incidents and a resident on resident altercation. LPA Yee met with Elizabeth Whittington, Executive Director. The reason for the visit was explained. On today's visit LPA Yee reviewed and obtained copies of files for Resident #1 - Resident #4, facility files throughout the visit, interviews were conducted with the Executive Director at 12:00pm, Staff #1 at 1:25pm, Jarred Massey-Baker, Director of Memory Care at 2:06pm Witness #1 at 11:17am, Resident #1 at 12:18am. The first incident of alleged resident abuse was reported to the Department on 1/17/24. Per the incident report, Resident #1 contacted a family member via telephone and informed them that the people here are hitting me. Per face to face interview with the family member, Resident #1 calls about 20 times a day. They informed facility staff about what Resident #1 told them. The family member states that the staff treats Resident #1 well and does not believe that the staff are hitting resident. The family member also heard Resident #1's spouse in the background loudly asking Resident #1 "what are you saying, no one is hitting you." Resident #1 and spouse are inseparable. Per interview with Resident #1, the staff hit them on their butt to wake them up. Resident #1 states that they don't like that. When Resident #1 was asked by the family member if it was a hit or was it a tap and the resident indicated that it was a tap but does not like being woken up that way. Per the family member, they will discuss with the Executive Director to get staff to tap Resident #1 on the shoulder instead. The second incident reported to the Department on 1/18/24 involved Resident #2 and Resident #3. Resident #2 slapped Resident #3 in the face. Per interview with the Executive Director and

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 VISTA SENIOR LIVING	FACILITY NUMBER: 197609969
	VISIT DATE: 02/07/2024

NARRATIVE

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Director of Memory Care, this was a one time incident and has not happened again. Resident #2 and Resident #3 are residents in the Memory Care Unit and they were sitting in the living room when staff heard a slapping sound. Upon inspection by staff, redness was observed on left side of Resident #3's face. Family of both residents were notified. Family of Resident #2 were shocked as the resident does not have a known prior history of hitting. Resident #2 physician's was also notified. The facility plan to ensure that Resident #3 is not hit again, is to keep both residents separated and monitor them closely.

The third incident was reported to the Department on 1/31/24 and involves Resident #4 and Staff #2. The incident reported to the Department was that Staff #1 and Staff #2(caregivers) were assisting Resident #4 get dressed and ready for the day around 6:35am. Resident #4 began to show signs of being agitated and raised both hands with closed fists. Conflicting verbal and written statements are being provided by Staff #1 and Staff #2 as to what occurred next. Per Staff #1, Staff #2 slapped Resident #4's hand and told resident "don't do that." Per Staff #2, Resident #4 was being aggressive and they raised their hand to protect themselves from being hit by Resident #4. This incident was reported to the Director of Memory Care by Staff #1. An immediate decision was made to place Staff #2 on suspension while the incident was being reviewed. Staff #2 was sent home on the day of the incident. The resident's family and physician were notified of the incident. An SOC341 Report of Suspected Dependent Adult/Elder Abuse was filed with Adult Protective Services and a LIC624 Special Incident Report was submitted to the Department. Training was provided on reporting requirements on 1/30/24 and Memory Care Residents: Redirecting & Communication was conducted on 1/18/24.

On 2/6/24, a conference call was made to Staff #2 to terminate employment with the facility and the final check was picked up by Staff #2 on 2/7/24.

Per investigation of all three reported incidents the facility took immediate and appropriate action to address each of the incidents. No citations were issued on today's visit.

Exit interview was conducted.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC809 (FAS) - (06/04)

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