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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610004
Report Date: 06/23/2021
Date Signed: 06/23/2021 02:08:34 PM

Document Has Been Signed on 06/23/2021 02:08 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 VIEW ASSISTED LIVINGFACILITY NUMBER:
197610004
ADMINISTRATOR:GASPARYAN, SUSANNAFACILITY TYPE:
740
ADDRESS:20565 CALIFA STREETTELEPHONE:
(747) 226-1408
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 4DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Susanna GasparyanTIME COMPLETED:
12:00 PM
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At 8:30 am Licensing Program Analyst (LPA) Sandra Urena conducted Infection Control call, and asked infection control questions before arriving at the facility. At 8:45am LPA was greeted by Caregiver. Administrator Susanna Gasparyan arrived at around 9:30am. LPA introduced herself and explained the reason for the visit. LPA conducted an unannounced required annual inspection visit.

Census: Four residents.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA was asked to fill out a comprehensive self-assessment questionnaire for detection of COVID symptoms. Temperature was taken by Caregiver. Infection Control signs were visible at entrance and throughout the facility.

Facility Tour: At 9:45am LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: At 9:45am LPA observed the kitchen/dining area. Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods.

Bedrooms: At 9:50am LPA observed the Resident’s bedrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Bathrooms: At 10:00am LPA observed the Resident’s restrooms. Restroom was clean, shower area was in clean condition with grab bars and non-skid mat available. Paper towels were available for drying hands. Hand washing sign was displayed.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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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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 VIEW ASSISTED LIVING
FACILITY NUMBER: 197610004
VISIT DATE: 06/23/2021
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Outdoor Space: At 10:10am LPA observed the Outdoor space. A pool is available in the backyard, pool is fenced, with locked gate. A shaded patio is available for residents to visit with family members. Side gate is unlocked.

Facility Records: At 10:15 am LPA reviewed staff and residents’ records. All flies are in good order, and meet


requirements.

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 has not had a confirmed case of COVID-19 at this time, the facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited at this time. Exit interview conducted. Signatures obtained. A copy of report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
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