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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421700411
Report Date: 06/29/2021
Date Signed: 06/30/2021 08:33:37 AM

Document Has Been Signed on 06/30/2021 08:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VALLE VERDEFACILITY NUMBER:
421700411
ADMINISTRATOR:SUSAN E PONCEFACILITY TYPE:
741
ADDRESS:900 CALLE DE LOS AMIGOSTELEPHONE:
(805) 883-4000
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY: 547CENSUS: 365DATE:
06/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Susan Ponce, AdministratorTIME COMPLETED:
05:40 PM
NARRATIVE
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This Case Management visit was conducted to address deficiencies noted during Complaint Control #29-AS-20210623155841 investigation visit conducted on 6/29/21. The Case Management visit is being conducted to discuss the serious illness/injury reporting requirement as per regulation 87211(a)(1) Reporting Requirements and 87632(d)(2) Hospice Care Waiver Notifications.
During today’s visit, LPA reviewed R1’s records and interviewed Administrator. Documents revealed on and 1/9/2021, 1/17/2021, and 6/20/2021, R1 sustained falls resulting in serious injuries. Administrator stated the falls were not reported to CCL. LPA advised Administrator that serious illness/injuries are required to be reported to CCL within seven (7) days of the incident(s) as required by California Code of Regulations.
Also during today’s visit, documents review revealed that R1 was placed on hospice on 1/9/2021. LPA determined facility staff did not notify CCL that R1 had been placed on hospice as required by California Code of Regulations.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, today's reports and appeal rights were reviewed. Due to technical issues, a copy of the report has been emailed to Administrator for signature.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2021 12:05 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/30/2021 10:32 AM


Created By: Kristin Kontilis On 06/29/2021 at 05:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLE VERDE
FACILITY NUMBER: 421700411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2021
Section Cited
CCR
87211(a)(1)

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Reporting Requirements: …(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence…
This requirement is not met as evidenced by:
*THIS IS AN AMENDED REPORT OF THE ORIGINAL REPORT DATED 6/29/2021.
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Administrator agrees to submit a written declaration stating the regulation in its entirety has been reviewed and Administrator will comply with said regulation.
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Based on records reviewed and interviews conducted, facility staff did not report falls R1 sustained resulting in serious injuries on 1/9/2021, 1/17/2021 and 6/20/2021 which poses an immediate health and safety risk to residents in care.
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Type B
06/30/2021
Section Cited
CCR87632(d)(2)

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Hospice Care Waiver: The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility...

This requirement is not met as evidenced by:
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Administrator agrees to submit a written declaration stating the regulation in its entirety has been reviewed and Administrator will comply with said regulation.
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Based on records reviewed and interview conducted, facility staff did not notify CCL of R1’s hospice placement on 1/9/2021.
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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:Kelly Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021


LIC809 (FAS) - (06/04)
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