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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610004
Report Date: 07/14/2023
Date Signed: 07/14/2023 04:10:20 PM


Document Has Been Signed on 07/14/2023 04:10 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 VIEW ASSISTED LIVINGFACILITY NUMBER:
197610004
ADMINISTRATOR:GASPARYAN, SUSANNAFACILITY TYPE:
740
ADDRESS:20565 CALIFA STREETTELEPHONE:
(747) 226-1408
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 6DATE:
07/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Susanna GasparyanTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Angel Ascencio arrived at the facility to conduct a required annual visit. The LPA met with Staff member at approximately 9:15 a.m. and explained the reason for
the visit. Administrator Susanna Gasparyan arrived at the facility shortly after.

The LPA along with Staff toured the physical plant areas inside and outside at approximately 09:30 a.m., to ensure that there are no health and safety hazards. This facility accepts resident under the Assisted Living Waiver Program (ALW).

BEDROOMS: There are four (4) bedrooms designated for resident use. Bedroom #1 and #4 are shared. Bedroom #2 and #3 are private rooms. Bedroom # 2 has access to private restroom. Bedroom #3 has a direct access to the outside and the bedroom is considered their bedridden room. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage.

BATHROOMS: Resident bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. The bathrooms hot water measured between 105.0 degrees Fahrenheit and 120.0 degrees Fahrenheit.

KITCHEN: Kitchen knives are stored in a locked cabinet in the kitchen. The supply of dishes,
utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees
Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable
food is adequate.
Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
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 VIEW ASSISTED LIVING
FACILITY NUMBER: 197610004
VISIT DATE: 07/14/2023
NARRATIVE
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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and
good condition. At the time of the visit, common seating area and dining room furniture was
observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social
distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system and carbon monoxide detector was tested and operated normally at the time of visit. Medications were observed to be locked in a cabinet in the kitchen and contained at least 30 days of worth of medication.

GARAGE: There is an attached garage containing a laundry room, cleaning supplies, additional Personal Protective Equipment (PPE) and incontinence supplies. The garage was observed locked. The administrator was reminded that it must be kept locked and inaccessible to residents at all times.

INFECTION CONTROL: During today’s visit, LPA Ascencio spoke with Administrator regarding the


facility’s infection control practices. There is 1 entry into the facility. Upon entry, the
facility has a central entry point for symptom screening. The LPA noted that the facility is allowing
visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal
Protective 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. The facility’s policies and procedures as it pertains to infection control are adequate.


The following was observed during today's visit:

At 09:35 a.m., during facility tour, LPA observed 5 out of 6 residents with bed rails. At 11:05 a.m., upon further review of resident files, 4 out of 6 residents did not have bed rail order.

Continued on LIC 9099 - C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
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 VIEW ASSISTED LIVING
FACILITY NUMBER: 197610004
VISIT DATE: 07/14/2023
NARRATIVE
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At 11:56 a.m., during medication review, LPA observed the Centrally Stored Medication Record was not accurate; Tylenol 500mg was not centrally stored, Eliquis Rx number did not match what was written, 1 Hydrocodone 325mg was not added to the Centrally Stored, 1 Pradexa 150 mg was not centrally stored and 6 out of 6 resident did not have the PRN Authorization letter.

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

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

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/14/2023 04:10 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: VALLEY VIEW ASSISTED LIVING
FACILITY NUMBER: 197610004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as Tylenol 500mg was not centrally stored, Eliquis Rx number did not match what was written, 1 Hydrocodone 325mg was not added to the Centrally Stored, 1 Pradexa 150 mg was not centrally stored which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Administrator will updated the Centrally Stored Medication Records to be accurate. Administrator will submit updated Centrally Stored Medication to LPA by 07/21/23.
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 6 out of 6 residents did not have the PRN Authorization Letter, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Administrator will submit the PRN Authorization letter to residents physicians. Administrator will send PRN letters to LPA by 07/21/23.
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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 07/14/2023 04:10 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: VALLEY VIEW ASSISTED LIVING
FACILITY NUMBER: 197610004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 4 out of 6 resident did not have the bed rail orders which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Administrator will obtain bed rail orders for residents who need bed rails. Administrator will submit to LPA by 07/21/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5