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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601684
Report Date: 08/16/2023
Date Signed: 08/16/2023 01:59:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/20/2022 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220720141811
FACILITY NAME:VALLEY VILLAGE LARKSPUR HOUSEFACILITY NUMBER:
198601684
ADMINISTRATOR:ALEXANDER KRASNOSHTEINFACILITY TYPE:
734
ADDRESS:15255 LARKSPUR STREETTELEPHONE:
(818) 587-9450
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:5CENSUS: 5DATE:
08/16/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Anthony TrabaTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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1. Facility did not ensure that staff completed required certifications
2. Facility staff's certifications are not kept on file at the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness met with Licensed Vocational Nurse Anthony Traba and informed him the reason of the visit. LPA was told former Administrator Kim Lozano is no longer working at the facility and there is a new Administrator. LPA is delivering final findings of the following allegations:

Allegation # 1: Facility did not ensure that staff completed required certifications. On July 29, 2022, from 9am to 1130am, LPA Gary Tan, conducted interviews and obtained documents pertaining to the complaint. On August 02, 2022 from 3pm to 4pm, LPA interviewed the complainant and obtained additional documents. It was reported to LPA T. Cabiness, by a reliable source, that facility staff did not have current first aid or AED (Automated Electronic Defriberator) certificates. Former Administrator Kim Lozano confirmed the deficiencies, and submitted valid certificates to LPA. Therefore, based on documentation, and interviews, the allegation is Substantiated. Note, deficiency issued, and plan of correction is cleared during this visit.

Allegation # 2: Facility staff's certifications are not kept on file at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
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 3
Control Number 31-AS-20220720141811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VILLAGE LARKSPUR HOUSE
FACILITY NUMBER: 198601684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2023
Section Cited
CCR
80075(f)
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Health Related Services: (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement was not met, evidenced by
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Current documentation and certificates emailed to LPA. POC cleared during the visit.
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based on a reliable source and documentation, facility staff did not have current first aid or AED certificates. This is a potential health and safety risk to clients in care.
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Type B
08/16/2023
Section Cited
CCR
80066(a)
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Personnel Records: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information. This requirement was not met, evidenced by, based on a reliable source and
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POC cleared during today's visit.
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documentation, facility personnel records and documents were not properly stored in staff files. This is a potential health and safety risk to clients 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220720141811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY VILLAGE LARKSPUR HOUSE
FACILITY NUMBER: 198601684
VISIT DATE: 08/16/2023
NARRATIVE
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 On July 29, 2022, from 9am to 1130am, LPA Gary Tan, conducted interviews and obtained documents pertaining to the complaint. On August 02, 2022 from 3pm to 4pm, LPA interviewed the complainant and obtained additional documents. It was reported to LPA T. Cabiness, by a reliable source, facility did not maintain proper documentation in personnel files. Former Administrator Kim Lozano confirmed the deficiencies, therefore, based on documentation, the allegation is Substantiated. Note, deficiency issued, and plan of correction is cleared during the visit.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3