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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610051
Report Date: 01/08/2024
Date Signed: 01/08/2024 06:05:20 PM


Document Has Been Signed on 01/08/2024 06:05 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 VILLAGE SENIOR LIVING, INC.FACILITY NUMBER:
197610051
ADMINISTRATOR:AYVAZYAN, SARGISFACILITY TYPE:
740
ADDRESS:5541 VANTAGE AVE.TELEPHONE:
(747) 253-0007
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:6CENSUS: 5DATE:
01/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:09 PM
MET WITH:Sargis Ayvazyan, AdministratorTIME COMPLETED:
06:10 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to deficiencies noted during a visit to the facility today. The reason for today's visit was provided.

During today's visit LPA Yee received information that the facility receives Resident #1's Social Security Income and State Supplemental Payment in the facility's bank account. A copy of the Surety Bond was requested and could not be provided. A request was made by the facility administrator to the facility's insurance agent to obtain coverage today and will not be available for a couple of days. Evidence that a Surety Bond with the appropriate limits will be provided to Licensing as soon as it becomes available.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview was conducted, Appeals Rights discussed and a copy was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/08/2024 06:05 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 VILLAGE SENIOR LIVING, INC.
FACILITY NUMBER: 197610051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2024
Section Cited
CCR
87216(a)(1)

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Bonding: Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.(1)The amount of the bond shall be in
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Licensee will purchase a Surety Bond in the amounts that will cover all resident funds handled by the facility. Evidence of an active Surety Bond will be provided to the Department by no later than 1/16/24
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accordance with the following schedule: Total Safeguarded Per Month Bond Required: $750 or less -$1,000, $751 to $1,500.- $2,000, $1,501 to $2,500 - $3,000 Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond. The facility does not have a surety bond for R1's SSI funds
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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: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
LIC809 (FAS) - (06/04)
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