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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609869
Report Date: 01/14/2022
Date Signed: 01/14/2022 03:41:02 PM

Document Has Been Signed on 01/14/2022 03:41 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VALLEY VILLA SENIOR LIVINGFACILITY NUMBER:
197609869
ADMINISTRATOR:SIMITYAN, ARMENUIFACILITY TYPE:
740
ADDRESS:8315 SPARTON AVETELEPHONE:
(818) 994-5223
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 6CENSUS: 4DATE:
01/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Josephine Calderon, StaffTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 12:52 p.m. LPA was greeted and screened by staff Josephine Calderon. The Administrator was not available at the time of the visit and authorized staff, Josephine Calderon to sign the report. This annual had a specific emphasis on infection control practices and procedures.

At 1:07 p.m. LPA and staff began the physical plant tour inside and outside to ensure there are no health and safety hazards and facility is in compliance with the Title 22 Regulations.

KITCHEN: At 1:08 p.m. LPA observed the kitchen/dining area. Knives are stored in the locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:09 p.m., kitchen hot water temperature measured at 107.0-degree Fahrenheit. At 2:14 p.m., LPA observed staff preparing lunch.

OUTDOOR SPACE: At 1:20 p.m., LPA observed the backyard, which has a covered outdoor area for resident use. The two side gates have latches for emergency exits.

BEDROOMS: LPA observed multiple resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Passageways were free and clear from obstruction. Inside temperature was maintained at a comfortable level.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skids mats. At 1:38 p.m. LPA observed hot water to be measured at 106.3-degree Fahrenheit.

Continued on LIC 809C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022
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 4
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: VALLEY VILLA SENIOR LIVING
FACILITY NUMBER: 197609869
VISIT DATE: 01/14/2022
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Continued from LIC 809.

COMMON AREAS: At 1:24 p.m., LPA observed common areas to be relatively clean and properly furnished.
Medications are located in a locked storage closet located near the activity room. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the laundry room.
Required signs such as the license and complaint poster are posted near the activity room. Signs are posted throughout facility to promote handwashing, cough/sneeze etiquette, and physical distancing.

At 1:50 p.m., fire alarms and carbon monoxide detectors were tested and were functioning properly. At 2:23 p.m., LPA observed the fire extinguisher to be fully charged and last serviced on 09/23/2021.

INFECTION CONTROL: During today’s visit, the LPA spoke with staff regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

Between 1:42 p.m. – 2:00 p.m., LPA conducted Infection Control mitigation module with staff.
The following recommendation are as follow:
- License should be posted in a prominent location for public view. Required postings are more accessible near the front entrance.
- Posting Provider Information Notices (PINs) in an easily accessible location to educate staff, residents, and families on changing policies and procedures from the Department.

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
LIC809 (FAS) - (06/04)
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