197609969-2-26-2024-29-AS-EPEI-D2U35S-20240226165714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609969
Report Date: 02/26/2024
Date Signed: 02/26/2024 04:57:52 PM

Document Has Been Signed on 02/26/2024 04:57 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: 64	DATE:	02/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Elizabeth Whittington, Executive Director		TIME COMPLETED:	05:15 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 Analysts (LPAs) Emily Peraldi and Sandra Urena arrived at the facility unannounced to conduct a required annual visit. At 10:05 a.m., the LPAs were greeted and screened by staff. At 10:15 a.m., the LPAs met with the Executive Director (ED), Elizabeth Whittington and explained the reason for the visit. At 10:36 a.m., the LPAs and the Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The facility is a five-story building. Resident rooms are located throughout four floors, all floors are assisted living except for floor three (3) which is designated for memory care. Common spaces on the first floor include the reception area/lobby, a theater, salon, dining room, and fitness room. The remaining floors each have their common spaces for activities, and all have appropriate furniture. All activity rooms and common spaces appeared clean and in good repair. Activity schedules are posted throughout the facility. There were no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which were charged and last serviced 01/05/2024. Fire alarm/sprinkler system test was documented and tested 08/2023. Kitchen: Dining is located on the first floor and was observed to be clean and sanitary. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was posted, and the facility offers daily specials and a standard selection at every meal. Snacks and beverages are available for residents. Resident Units: The LPAs and Executive Director toured seven (7) randomly selected resident rooms throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Continued on LIC 809C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
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 04:57 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as in seven (7) residents centrally stored medications and destruction record (CSMDR) were not properly documented which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2024
	Plan of Correction
1 2 3 4	The Executive Director will send a date for staff training regarding medication and submit documentation to CCL.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
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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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: 02/26/2024

NARRATIVE

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Restrooms: The LPAs and Executive Director observed restrooms in seven (7) resident units and common area restrooms. All restrooms were fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces in the bathing unit. Water temperature was tested throughout the visit, and water measured between 105.1 – 116.6 degrees Fahrenheit.

Outside areas: There are multiple outdoor patios equipped with furniture for resident use. There were no bodies of water noted. Parking is available for residents and visitors.

Files: Between 11:40 a.m. and 2:25 p.m., the LPAs conducted a file review for six (6) residents and six (6) staff. Six (6) resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. Six (6) personnel records were reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and training documentation showing required training completed. Personnel files were in order.

Starting at 2:30 p.m., the LPAs conducted a review of medication records, policy and procedures with the Executive Director. Audit for seven (7) residents revealed that facility staff did not accurately record medications, and/or missing start dates. The Executive Director stated that facility staff will receive medication training.

Documentation: The LPAs obtained a copy of the liability insurance, resident roster, and staff roster.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiency was cited (refer to LIC 809-D). The Executive Director was made aware that failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
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

LIC809 (FAS) - (06/04)

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