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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601684
Report Date: 11/19/2024
Date Signed: 11/19/2024 01:49:14 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
11/18/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20241118113211
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: 5DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Amparo Murvin - AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not ensure to abide by own plan of operation
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Administrator Amparo Murvin and explained the reason for the visit.

LPA conducted physical plant tour at 9:34 AM, requested copies of facility document relevant to the investigation at 9:55 AM and reviewed records between 10:00 AM to 11:30 AM. It was alleged that two (2) staff members of the facility did not have required certifications based on their own plan of operations. LPA's record review today between 10:00 AM to 11:30 AM, confirmed that based on the review of Department of Developmental Services (DDS) on 08/28/24 and 08/29/24, Staff #1 (S1) and Staff #2 (S2) did not have Direct Support Professional (DSP) training certificates on file as required by their plan of operation. Based on the information gathered during this visit, the allegation is deemed substantiated at this time. Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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 2
Control Number 31-AS-20241118113211
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: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2024
Section Cited
CCR
80022(b)(6)
1
2
3
4
5
6
7
Plan for inservice education of staff if required by regulations governing the specific facility category.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The administrator stated that one staff is currently on DSP training and will submit a copy of the certificate on or before the POC date but the RN was removed on the roster due to scheduling conflict as he is working full time in the hospital and unable to do the training.
8
9
10
11
12
13
14
Based on NLARC CAP dated 11/05/24, and LPA review today, the licensee did not ensure that the facility staff abide by the facility's plan of operation which poses a potential health and safety risk to the residents in care.
8
9
10
11
12
13
14
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: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2