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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609869
Report Date: 12/22/2022
Date Signed: 12/22/2022 12:15:37 PM

Unfounded


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
12/07/2022 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20221207113908
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:
12/22/2022
UNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Josephine Calderon, StaffTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not observe resident's change in condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 11:52 a.m., the LPA met with facility staff and explained the reason for the visit. At 11:54 a.m., the LPA spoke with the Administrator over the phone. The Administrator was not available at the time of the visit and authorized staff, Josephine Calderon to sign the report.

During the initial visit on 12/13/2022, at 10:31 a.m., the LPA conducted an interview with the Administrator and requested documents. On 12/13/2022 at 10:37 a.m., the LPA conducted a brief physical plant tour. On 12/14/2022 at 2:53 p.m., the LPA conducted an interview with a representative from the Mission Hills Police Station. Additionally, the LPA reviewed facility files on 12/15/2022.

Continued on LIC 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
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-20221207113908
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: 12/22/2022
NARRATIVE
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Regarding the allegation: Staff did not observe resident's change in condition.
On 12/07/2022, the Department received a complaint alleging that the facility staff did not observe Resident #1’s (R1’s) change in condition which led to staff calling 9-1-1 for R1. Interview conducted with the Administrator on 12/13/2022 revealed that R1 never resided at this facility. The Administrator stated that they did not know the resident in question. Interview conducted on 12/14/2022 with the Mission Hills Police Station confirmed that R1 did not reside at this facility and that the police responded to a different address for R1. Further review of facility files revealed that R1 did not reside at this facility. Based on the information obtained, there was no evidence to support the allegation, therefore, the above allegation is deemed Unfounded at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis.

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: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2