197609869-12-1-2022-29-AS-DPEA-CN6TEF-20230117133951

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609869
Report Date: 12/01/2022
Date Signed: 12/01/2022 01:18:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20221005095839

FACILITY NAME:	VALLEY VILLA SENIOR LIVING		FACILITY NUMBER:	197609869
ADMINISTRATOR:	SIMITYAN, ARMENUI		FACILITY TYPE:	740
ADDRESS:	8315 SPARTON AVE		TELEPHONE:	(818) 994-5223
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 5	DATE:	12/01/2022
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Armenui Simityan, Administrator, Josephine Calderon, Staff		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to safeguard resident's personal belongings.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced subsequent complaint visit at the facility today. At 9:34 a.m., the LPA met with facility staff and explained the reason for the visit. At 11:13 a.m., the Administrator arrived at the facility.

During the initial visit on 10/05/2022, LPA Emily Peraldi conducted a brief physical plant tour and interviewed the Administrator. Additionally, on 10/05/2022, the LPA requested pertinent documents. On 11/30/2022 between 1:10 p.m. and 3:56 p.m., the LPA conducted interviews with five (5) resident’s families or responsible persons. During today’s visit on 12/01/2022, the LPA conducted a physical plant tour at 9:46 a.m. On 12/01/2022 between 10:44 a.m. and 11:12 a.m., the LPA conducted interviews with five (5) out of five (5) residents. On 12/01/2022, at 11:14 a.m., the LPA conducted an interview with the Administrator. The LPA also interviewed two (2) staff on 12/01/2022 at 11:35 a.m. On 12/01/2022, at 12:45 p.m., the LPA conducted an interview with Resident #1 (R1) Power of Attorney (POA). Contiued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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 29-AS-20221005095839

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/01/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation: Facility failed to safeguard resident's personal belongings.
On 10/05/2022, the Department received a complaint in which it was alleged that the facility has not been safeguarding resident’s personal belongings by allowing another resident take personal items from R1. Interview with the Administrator revealed that R1 was recently looking for a personal item. The Administrator explained that they had a meeting with R1’s POA and it was revealed that the personal items were with R1’s POA. On 12/01/2022, at 12:45 p.m., the LPA confirmed that the personal items are in possession with R1’s POA. R1’s POA also confirmed that R1’s personal items have not been stolen or have not gone missing. R1’s POA explained that R1’s also has a storage unit where many of R1’s personal items are located. Additionally, interviews conducted with other residents’ families and responsible persons revealed that personal belongings have not gone missing from residents’ rooms. The interviews with residents revealed that there has not been missing items from their rooms nor has there been another resident taking items from rooms. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted. The Administrator left during the time of the visit and authorized staff, Josephine Calderon to sign the report A copy of the report will be issued via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2