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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601684
Report Date: 03/10/2025
Date Signed: 03/10/2025 01:32:26 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.RO, 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
03/03/2025 and conducted by Evaluator Perchui Khurshudyan
COMPLAINT CONTROL NUMBER: 31-AS-20250303094517
FACILITY NAME:VALLEY VILLAGE LARKSPUR HOUSEFACILITY NUMBER:
198601684
ADMINISTRATOR:KIMBERLY LOZANOFACILITY TYPE:
734
ADDRESS:15255 LARKSPUR STREETTELEPHONE:
(818) 587-9450
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:5CENSUS: 4DATE:
03/10/2025
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Anthony Traba - LVNTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff are not providing adequate activities to residents
INVESTIGATION FINDINGS:
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On 3/10/2025, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced, initial 10-day complaint visit to investigate the above allegation. Upon arrival, LPA met with the Program Aide Karina Najarro, introduced herself by showing her badge and explained the reason for the visit. LPA was informed that the facility Administrator Amparo Murvin is not available, however, LVN Anthony Traba will be helping with the visit and is designee to sign reports.
Note: LPA noticed that facility profile shows Kimberly Lozano as an Administrator for the facility, however, was informed by LVN that new administrator Amparo Murvin took over the position for 2 years already. LPA collected new administrator’s certificate which was expired on 1/31/2025 and was informed that the renewed certificate is still pending. LPA collected receipt confirming the renewal request.

LPAs requested resident and staff rosters and conducted a physical plant tour with the help of Anthony Traba, to ensure health and safety of the clients are protected and physical plant is in compliance with Title 22 Regulations. LPA observed that the house is generally clean, organized and in good repair.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
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-20250303094517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY VILLAGE LARKSPUR HOUSE
FACILITY NUMBER: 198601684
VISIT DATE: 03/10/2025
NARRATIVE
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At 10:30am LPA requested and reviewed client files and obtained copies of pertinent documents which include, but not limited to Admission Agreement, Physician Reports, Individual Program Plan (IPP), the Facility Program Design, Day Program schedule, and monthly Activity Schedules.

It was reported that on 1/29/2025, a credible witness from North Los Angeles Regional Center (NLARC) conducted an unannounced visit to the facility and requested social and recreational activities/outings calendars and documentation. The Administrator could not provide documentation of any outings provided to the clients. NLARC identified there were no social and/or recreational activities provided in the community to the residents from July 2024 through November 2024.

During the visit, LPA conducted interviews with LVN, three (3) Program Aids working for the AM shift. LPA was unable to interview clients in care due to clients being non-verbal and one (1) out of four (4) clients who is verbal was sleeping.

The information obtained during the interview confirmed the allegation and statements were made that although there is a monthly schedule for social and recreational activities to provide clients in care, they were never provided and/or documented, therefore, the Allegation is Substantiated.



Exit interview conducted, Deficiency issued on LIC9099-D

Copy of appeal rights and report delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20250303094517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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: 03/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2025
Section Cited
CCR
80065(a)(f)(6)
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Personnel Requirement:(a)Facility personnel shall be competent to provide the services necessary...at all times be employed in numbers... to meet such needs(f)All personnel shall be given on-the-job training...(6)Availability of community services and resources. This requirement is not met as evidenced by:
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The Administrator will ensure social and recreational activities are provided weekly to all residents, will develop a plan to implement an activity/outing schedules to meet the residents IPP goal and social needs. The Administration agrees to submit weekly/monthly activity/outing calendars to LPA by POC due date.



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Based on interviews, observation, document review and inspection, the Administrator did not comply with the section cited above by failing to provide social and recreational activities to clinets in care for five (5) months. This poses a potential health and safety risk to residents 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3