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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609869
Report Date: 12/01/2022
Date Signed: 12/01/2022 01:17:10 PM

Document Has Been Signed on 12/01/2022 01:17 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: 5DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Armenui Simityan, Administrator, Josephine Calderon, StaffTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:34 a.m., the LPA was greeted by staff. At 11:13 a.m., the Administrator arrived at the facility. This annual had a specific emphasis on infection control practices and procedures.

At 9:46 a.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 9:49 a.m., hot water measured at 105.6-degree Fahrenheit.

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

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 10:00 a.m., hot water measured at 107.5-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels.

OUTDOOR SPACE: At 9:54 a.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction.

Continued on LIC-809.
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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 12/01/2022
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COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 10/20/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 10:07 a.m., fire alarms/carbon monoxide detectors were tested and functioned properly. At 11:50 a.m., the LPA observed a daybed in the activity room, however the Administrator explained that nobody uses the bed, neither staff nor residents. Medications and first aid kits are located in a locked storage closet near the activity room.

GARAGE: The garage is attached to the house. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for temperature checks, and a sanitation station. The LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. The Administrator left during the time of the visit and authorized staff, Josephine Calderon to sign the report. Exit interview conducted and report issued, and a copy of the report was provided 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
LIC809 (FAS) - (06/04)
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