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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850549
Report Date: 07/17/2025
Date Signed: 07/17/2025 02:59:25 PM

Document Has Been Signed on 07/17/2025 02:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VALLEY PARADISE BOARDING CAREFACILITY NUMBER:
195850549
ADMINISTRATOR/
DIRECTOR:		NIKOYAN, NAIRAFACILITY TYPE:
740
ADDRESS:12200 HATTERAS STTELEPHONE:
(818) 853-7278
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 6CENSUS: 4DATE:
07/17/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Naira Nikoyan - LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a post-licensing continuation visit at 9:40AM. The LPA met with the Licensee Naira Nikoyan and explained the reason for the visit. Entrance interview conducted.

At 10:10AM, the LPA and the Licensee briefly toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. At this time, no immediate health and safety hazards were observed.

During the initial visit on 07/11/2025, the LPA observed the following:

PHYSICAL PLANT: In the food pantry located in the hallway, the LPA observed expired non-perishable foods dated from 10/27/2022 to 05/28/2025. The Licensee was unaware of the expired food and stated they would update the pantry. Resident #1 (R1) resided in the second living room and was observed to have oxygen administered. Residents in Bedroom #3 also had oxygen stored in their room for use as needed. The LPA did not observe signage stating oxygen was in use for these areas, but did observe one signage for Bedroom #1. The Licensee stated that R1 was not receiving oxygen, and the LPA pointed out the operating oxygen machine attached to the foot of R1’s hospital bed. The Licensee stated Resident #2 (R2) and Resident #3 (R3) were not currently receiving oxygen but utilize it sometimes.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 12
Document Has Been Signed on 07/17/2025 02:59 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/17/2025 at 01:31 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY PARADISE BOARDING CARE
FACILITY NUMBER: 195850549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in the Licensee did not maintain an Infection Control Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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The Licensee will complete and maintain their Infection Control Plan at the facility, review it annually, and send CCLD proof by POC due date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one restroom sink was observed to be clogged which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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The Licensee unclogged the sink's drainage. POC Cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 07/17/2025 02:59 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/17/2025 at 01:31 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY PARADISE BOARDING CARE
FACILITY NUMBER: 195850549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 2 resident restrooms did not have grab bars which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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The Licensee will install grab bars near the toilet and in the shower in the restroom in Bedroom #1. The Licensee will send CCLD proof by POC due date.
Type B
Section Cited
CCR
87412(a)
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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 Staff did not have personnel records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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The Licensee will complete 2 Staff's personnel record and store it in a centralized location at the facility. The Licensee will send CCLD proof by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 07/17/2025 02:59 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/17/2025 at 01:31 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY PARADISE BOARDING CARE
FACILITY NUMBER: 195850549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 Staff did not receive training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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The Licensee will review training regulations, implement a plan for Staff training, and complete a statement of understanding. The Licensee will send CCLD proof by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 07/17/2025 02:59 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/17/2025 at 01:31 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY PARADISE BOARDING CARE
FACILITY NUMBER: 195850549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(28)
General Food Service Requirements
(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in fridge food and non-perishables were expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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The Licensee will review the facility's food supply, discard expired food, and update food supply if necessary. The Licensee will submit a statement of understanding outlining food service regulation by POC due date.
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in the licensee did not maintain centrally stored medications and prescription labels were altered which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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The Licensee will review incidental and medical service regulations and update 4 residents' centrally stored records. The Licensee will send proof to CCLD by POC due date with a statement of understanding.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 07/17/2025 02:59 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/17/2025 at 01:31 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY PARADISE BOARDING CARE
FACILITY NUMBER: 195850549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in residents did not have a PRN Authorization Letter or PRN administration logs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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The Licensee will obtain PRN Authoriation Letters for all residents and create a PRN administration and refusal log. The Licensee will send CCLD proof of these documents by POC due date.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in resident records were not maintained on the facility, or in a centralized location, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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2
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4
The Licensee will maintain resident files in a centralized location in the facility and send CCLD proof by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 07/17/2025 02:59 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/17/2025 at 01:31 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY PARADISE BOARDING CARE
FACILITY NUMBER: 195850549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 4 out of 4 residents did not have any completed documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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2
3
4
The Licensee will complete resident records, obtain signatures, and provide copies to the residents and/or their POAs. The Licensee will provide CCLD complete files for all 4 residents by POC due date.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in the Licensee did not maintain an Emergency Disaster Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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2
3
4
The Licensee will complete and maintain their Emergency Disaster Plan at the facility, review it annually, and send CCLD proof by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 07/17/2025 02:59 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/17/2025 at 01:31 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY PARADISE BOARDING CARE
FACILITY NUMBER: 195850549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 3 resident bedrooms did not have "oxygen in use" signs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
1
2
3
4
The Licensee posted "oxygen in use" sign on the bedroom. POC cleared.
Type B
Section Cited
HSC
1569.695
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill ... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in the facility did not conduct emergency drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
1
2
3
4
The Licensee will create a schedule to conduct emergency drills and send CCLD this schedule with a template of how the Licensee plans to document the drills.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 PARADISE BOARDING CARE
FACILITY NUMBER: 195850549
VISIT DATE: 07/17/2025
NARRATIVE
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The LPA informed the Licensee that signage of “oxygen in use” need to be posted for safety reasons. In Bedroom #1’s private restroom, the LPA did not observe grab bars along the toilet nor the shower. Additionally, the sink in the restroom was clogged and slow to drain. The Licensee stated that the Hospice nurses utilized the sink to discard water used for the residents’ showers and advised them not to do so.

MEDICATIONS: Medications were reviewed for R2 and R3. For R2, three (3) PRN (as needed) medications were observed (Senna-Time 8.6MG, Melatonin 5 MG, and Hydrocodone-Acetamin 5-325MG) and did not have PRN Authorization Letter on file. Several of R2’s prescribed medications were not recorded on a Centrally Stored Medication and Destruction Record (CSMDR) which included Potassium CL ER 10 MEQ filled on 07/02/2025, One Daily Vitamin, Metformin HCL 500MG, Fenofibrate 54MG, and Atorvastatin 10MG each filled on 07/06/2025. Metformin HCL 500MG prescribed on 06/09/2025 was instructed for R2 to take 4 tablets daily, and one dose of 4 tablets remained. R2’s Furosemide 40MG, filled and started on 07/02/2025, was prescribed at 1 tablet twice daily but had not been administered. Cranberry 450MG also filled and started on 07/02/2025 had 6 tablets prepped by Staff and 8 tablets were administered; however, 10 total tablets should have been administered, indicating a discrepancy.

R3 had three (3) PRN medications (Hydralazine 25MG, Hydrocodone-Acetamin 5-325MG, and Lorazepam 0.5MG) but did not have a PRN Authorization Letter, nor were any administration logs recorded. Medications filled on 07/06/2025 including Losartan Potassium 25Mg, Glipizide 5MG, and Gabapentin 300MG were scheduled to begin 07/01/2025, were not administered. Melatonin 10MG, filled and started on 07/08/2025, had also not been administered as prescribed. R3’s Nortriptyline HCL 25MG, filled on 07/06/2025 and started 07/01/2025 had 7 tablets prepared by Staff and only 5 tablets taken by R3. Both trazodone 100MG and Atorvastatin 40MG had 7 tablets prepared by Staff, and the remaining tablet counts did not align with the expected usage. Glipizide 5MG filled and started on 06/07/2025 was prescribed at 1 tablet twice daily; it was observed that 19 tablets had been taken from the Morning pack and 10 tablets taken from the Evening pack. The total usage and prescription instructions suggested the medication should have been completed.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 10 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 PARADISE BOARDING CARE
FACILITY NUMBER: 195850549
VISIT DATE: 07/17/2025
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Gabapentin 300MG, also filled on 06/07/2025 and taken three times daily, was noted to have 7 capsules left in the Morning pack, 8 in the Evening pack, and the Bedtime pack was unaccounted for. R3’s Furosemide 20MG, filled and started on 06/23/2025, was prescribed for daily intake unless blood pressure dropped below 110 or heart rate below 60. 8 tablets remained, and there was no documentation indicating the medication had been held. Two (2) packs of Jardiane 25MG were observed for R3, both prescribed for daily use. The first pack contained 25 tablets, while the second contained 9 tablets. These packs were filled two (2) days apart, with labels observed to be altered. The Jardiane 25MG was not properly recorded on the CSMDR.

The Licensee stated that the residents did not need to take certain medications because they were already taking medications that addressed those same issues. The Licensee did not follow the medication prescription labels and stated that the residents did not want to take the medications, and the Licensee stopped offering them. The Licensee did not order the residents’ medications, but the Hospice Agency was responsible for it, and the Licensee was following the Hospice Nurses’ instructions. The LPA informed the Licensee that they need to follow the Physician’s orders and administer medications according to the medication labels. If the Licensee observed a change in the resident, the Licensee would need to contact the prescribing Physician to make adjustments. The LPA also informed the Licensee that there needs to be documentation of resident refusals, and the Licensee would need to continue offering the medications and inform the prescribing Physician. Additionally, PRN medications need to be documented each time they are administered which include the reason for the administration, date, and time. The CSMDR also showed inconsistencies pertaining to the date filled and date started of each medication. The LPA also discussed with the Licensee reporting requirements, as R3 was observed to be admitted to the hospital.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 11 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 PARADISE BOARDING CARE
FACILITY NUMBER: 195850549
VISIT DATE: 07/17/2025
NARRATIVE
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RECORDS: Record review of resident files revealed that R2, R3, and Resident #4 (R4) did not have completed documents such as Admission Agreements, Appraisals, Personal Rights, and Consent Forms. R2 and R3 had Physician’s Reports, however, R4 did not have their Physician’s Report or TB test results. R1 was admitted to the facility on 07/09/2025 and the Licensee did not complete any required documents upon admission to the facility. The Licensee stated they were waiting for R1’s family and Hospice to provide the documents. The LPA informed the Licensee that the required documents should be completed prior to being admitted to the facility. The Licensee stated they would work on obtaining and completing the required documents for all residents.

The LPA was not able to complete a review of Personnel records because the Licensee did not have any documentation completed for two (2) Staff in addition to both Staff not being fingerprint cleared. Staff #1 (S1) had been employed since 02/25/2025 and assisted residents as well as maintained facility files. Staff #2 (S2) had been employed since 07/02/2025 and had since been the primary caregiver in addition to the Licensee. S1 and S2 did not obtain their First Aid/CPR training or receive their 40 hours of initial training. S1 and S2 need to complete their Personnel Records, Health Screening with TB test results, First Aid/CPR Training, Criminal Record Statement and Clearance, and 40 hours of initial training.

The facility has not conducted any emergency drills or maintained their Infection Control Plan and Emergency Disaster Plan. The LPA requested the documents and the Licensee and S1 were unable to provide them. Additionally, files were not readily available nor kept and maintained in a centrally stored location on the facility’s premises.

Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies are cited (Refer to LIC 809-D).

Exit interview conducted. A copy of today’s report and appeal rights were reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 12 of 12