197609969-11-4-2025-29-AS-CYEE-DN52LJ-20251104162938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609969
Report Date: 11/04/2025
Date Signed: 11/04/2025 04:29:56 PM

Document Has Been Signed on 11/04/2025 04:29 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 VISTA SENIOR LIVING		FACILITY NUMBER:	197609969
ADMINISTRATOR/ DIRECTOR:	ELIZABETH J WHITTINGTON		FACILITY TYPE:	740
ADDRESS:	7040 VAN NUYS BLVD		TELEPHONE:	(818) 906-4400
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 164		CENSUS: 91	DATE:	11/04/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:25 AM
MET WITH:	Aaron Mayes, Designated Executive Director		TIME VISIT/ INSPECTION COMPLETED:	04:40 PM

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	Licensing Program Analyst (LPA) Christine Yee conducted an unannounced Case Management visit to investigate the incident that occurred on 10/12/25 and reported to the Department on 10/17/25, regarding Resident #1. LPA Yee met with Aaron Mays, Designated Executive Director. The reason for today's visit was explained. Per information provided on the LIC624, Special Incident Report, Staff #2 observed Staff #1 push Resident #1. No other details were provided regarding the incident on the report. Upon further inquiry into the incident, the following was revealed. On 10/12/25, around 4am, Staff #1, who works the night shift was doing laundry and had left the laundry cart with Resident #2's clothes by their door and had stepped away. Resident #1, who has dementia was wandering around, grabbed a pair of Resident #2's pants from the cart. Staff #1 noticed and attempted to get the pants away from Resident #1. Resident #1 got mad and threw the pants on the floor and began stepping on it. Staff #1 and Staff #2 attempted to get the resident off the pants. Staff #1 got irritated and pushed the resident, causing the resident to fall on the floor and landing on their back. Staff #1 and Staff #2, both assisted Resident #1 to get up. Resident #1 walked with a limp. Per Staff #2, when they were changing Resident #1, a big bruise was observed on the resident's arm and bottom. This incident was reported to Staff #3 when Staff #2 returned to work later that evening. Staff #4 was not advised of the 10/12/25 incident until 10/14/25. Staff #1 who was off on 10/13/25, was suspended via telephone on 10/14/25 by Staff #4 and the designated Executive Director was also notified that morning. An internal investigation was attempted and Staff #1 was given the opportunity to come into the office continued on LIC9099-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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)

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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 VISTA SENIOR LIVING	FACILITY NUMBER: 197609969
	VISIT DATE: 11/04/2025

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to provide a written statement of the incident that occurred on 10/12/25 and Staff #1 refused. Staff #1's employment was terminated on 10/17/25.

On today's visit, LPA Yee interviewed Staff #4 at 11:49pm, Designated Executive Director at 12:14pm and reviewed and obtained documents from Staff #1, Staff #2 and Staff #3's files, documents from Resident #1's file. A copy of the facility's investigation was obtained. A copy of the video clip of the incident was also obtained during the visit.

Per information obtained on today's visit, additional interviews and further investigation is needed to determine if the facility would be culpable for the action of the staff and if any further action is needed.

LPA Yee will return to deliver her findings of her investigation once the investigation into the incident has been completed.

Exit interview was conducted with Joanna Hernandez, Memory Card Director.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025

LIC809 (FAS) - (06/04)

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