<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610051
Report Date: 01/08/2024
Date Signed: 01/08/2024 06:00:26 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/03/2024 and conducted by Evaluator Christine Yee
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20240103145010
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
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Sargis Ayvazyan, AdministratorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
1. Staff are not ensuring resident receives Personal and Incidental Allowance (P&I)
2. Staff did not ensure resident receives mail

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegations and was let into the facility by Alisa Arshakyan, Staff. Sargis Ayvazyan, Administrator was contacted by telephone and he arrived at 11:17am to conduct the visit. The reason for today's visit was provided.

On today's visit, LPA Yee conducted an interview with the Administrator at 11:29am, Resident #1 at 12:13pm reviewed and obtained copies of Resident #1's file at 12:01pm.

Per information received from interviews conducted with the Administrator and Resident #1 on today's visit regarding Allegation #1 - staff are not ensuring resident receives Personal and Incidental allowance(P&I), both state that Resident #1 receives $60.00 dollars every month since August 2023. The facility became the
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20240103145010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/08/2024
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
26
27
28
29
30
31
32
the payee for Resident #1's funds in July 2023 but no P & I amount was included until August 2023. Per the Administrator, Resident #1 is a smoker and they purchase 3 cartons of cigarettes for a total of ninety dollars($90.00) and charge Resident #1, eighteen dollars ($18.00) for incontinence products. The balance of sixty dollars($60.00) is given to Resident #1. Resident #1 confirmed that $60.00 was received for January 2024. However, the facility does owe Resident #1 an additional seventeen dollars for January 2024 due to an increase in the P & I amount from $168.00 to $177.00 per month effective 1/1/24. The facility also needs to reimburse the resident $108.00 (6 months x $18) for the incontinent products charged from August 2023-January 2024 as the incontinence products are covered under the basic Social Security Income and State Supplemental Payment rate. The Administrator will provide evidence to Licensing that the resident has been provided with the difference in the P & I rate and the reimbursement for the incontinence charges totaling $125.00 by not later than 1/12/24. Based on the information received on today's visit, there was insufficient evidence to conclude that the facility failed to ensure that Resident #1 received their P & I allowance, therefore, Allegation #1 is UNSUBSTANTIATED.

Regarding Allegation #2 - Staff did not ensure that Resident receives mail, per the information received on today's interviews, Resident #1 receives mail but the complaint was generated as a result of a package that was sent to Resident #1 by family, was not received. Per information received, the facility has issues with receiving packages due to the way the facility is situated. The facility is located behind a family home with a separate address of 5539 Vantage Avenue. The facility is located at the end down a long drive way and their packages are delivered in error to the front house and this is not a issue as the facility has access to the front house. In the case of this complaint, Resident #1's package was addressed incorrectly to 5529 Vantage Avenue and is a non-existent address. Resident #1 did not receive the package as a result of the error in the address used by the family and not due to the facility's failure to ensure that the resident receives mail. Therefore, Allegation #2 is UNSUBSTANTIATED.


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

Exit interview was conducted, APPEALS RIGHTS were 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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/03/2024 and conducted by Evaluator Christine Yee
COMPLAINT CONTROL NUMBER: 29-AS-20240103145010

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
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Sargis Ayvazyan, AdministratorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
3. Staff are not allowing resident to leave the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegations and was let into the facility by Alisa Arshakyan, Staff. Sargis Ayvazyan, Administrator was contacted by telephone and he arrived at 11:17am to conduct the visit. The reason for today's visit was provided.

On today's visit, LPA Yee conducted an interview with the Administrator at 11:29am, Resident #1 at 12:13pm reviewed and obtained copies of Resident #1's file at 12:01pm.

Per review of Resident #1's files and interviews conducted regarding Allegation #3 - Staff are not allowing resident to leave the facility, per review of Resident #1's file, resident is determined by the physician to have mild cognitive impairment but is able to leave the facility unassisted. Per interview with the Administrator,
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20240103145010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/08/2024
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
26
27
28
29
30
31
32
Resident #1 has never been told that they may not leave the facility. Per the Administrator, Resident #1 resident goes out everyday with staff. Staff takes Resident #1 to Starbucks everyday and pays for his drinks and to 711 as needed. Per the Administrator, the resident is supervised by the staff due to concerns with Resident #1 purchasing alcohol and easily getting tired when walking distances and seating on the ground. Staff escorts Resident #1 and uses a wheelchair when resident tires. Per interview with Resident #1, they are told that they may not go out in the community alone due to their diagnosis of dementia which is bogus per Resident #1. Staff prevents Resident #1 from leaving the facility and has chased Resident #1 to the corner when resident leaves the facility without staffs' knowledge. Resident #1 is allowed to leave the facility only when supervised by staff. Resident #1 specifically asked LPA to let the Administrator know that Resident #1 can leave the facility unsupervised. By the actions of the facility, Resident #1 feels that they are not allowed to leave the facility unsupervised. Based on the information received on today's visit, Allegation #3 is SUBSTANTIATED.


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

Exit interview was conducted, APPEALS RIGHTS were 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20240103145010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
01/09/2024
Section Cited
CCR
87468.1(a)(6)
1
2
3
4
5
6
7
Personal Rights: (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from
1
2
3
4
5
6
7
Licensee will ensure that the residents are allowed to leave the facility unsupervised if they have been determined by their physician to be able to leave the facility unassisted. Provide a written and signed plan of action that the facility will implemement to ensure that residents are allowed to leave the
8
9
10
11
12
13
14
establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. Resident#1 who is determined to be able to leave facility unassisted, is not allowed to leave the facility un-supervised until today
8
9
10
11
12
13
14
facility by 1/9/24
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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
LIC9099 (FAS) - (06/04)
Page: 5 of 5