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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609969
Report Date: 02/26/2024
Date Signed: 02/26/2024 05:01:09 PM


Document Has Been Signed on 02/26/2024 05:01 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: 64DATE:
02/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Elizabeth WhittingtonTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Sandra Urena and Emily Peraldi arrived at the facility unannounced to conduct a case management-deficiency as a result of the Licensee's failure to inform the Department about the court appointed Receivership. The LPAs met with the Executive Director Elizabeth Whittington and informed them of the reason for the visit.

On 02/16/2024 the facility received a visit from Mr. Tom Seaman to inform the Executive Director that the facility was placed under Receivership, and that they were court appointed as the Receiver. However, the facility failed to inform the Department until the 21st of February 2024.

Per California Health and Safety Code section 1569.686, you are hearby notified that a $100 civil penalty is being assessed per day. The total civil penalty for a continuous violation shall not exceed $2000. You will receive an invoice in the mail. Payment is due when billed. Payments must be made by a personal business or cashier's check or money order made payable to the "California Department Of Social Services". Please write the facility number and invoice number on your check and include copy of your invoice with the payment. You will find the invoice number on your invoice. DO NOT SEND CASH.


The licensee was notified that a civil penalty is being assessed for failure to comply with this
section and/or failure to report specified events, in writing, within 2 business days to the Department, the state long term ombudsman, all residents, and their representatives. Deficiency cited under Health and Safety code 1569.686.
Pursuant to Health and Safety Code, the following deficiency was cited (refer to LIC 809-D).

Exit interview conducted/ Citations issued/ Civil Penalty assessed/ Appeal Rights discussed/ A copy of report


was issued.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
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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Document Has Been Signed on 02/26/2024 05:01 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2024
Section Cited
HSC
1569.686(a)(4)

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1569.686 A licensee shall notify the
department, the State Long-Term Care
Ombudsman, all residents, and, if applicable,
their legal representatives, in writing, within two business days...(1) A notice of default...This requirement is not met as evidenced by:
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Licensee stated they will inform the LTCO,
residents, and their responsible parties of the
notice of default by 03/01/2024.
Civil penalty is assessed for violation of
this section [Health and Safety code
1569.686(c)]
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Based on interview, licensee failed to ensure The Department, LTCO, residents and their responsible parties were notified of the default received by licensee on 02/16/204, which caused an immediate 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
LIC809 (FAS) - (06/04)
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