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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610004
Report Date: 05/18/2022
Date Signed: 05/18/2022 02:52:27 PM

Substantiated


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
11/23/2020 and conducted by Evaluator Martha Guzman-Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20201123113645
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: 3DATE:
05/18/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Susanna GasparyanTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Absence of Supervision

Facility staff are not fingerprint cleared and/or associated to the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 11/23/2020 by LPA A. Richardson. On today’s visit, LPA Guzman Chavez met with Administrator, Susanna Gasparyan. Entrance interview conducted.

During the initial visit on 11/23/2021, LPA A. Richardson conducted a virtual tour of the physical plant with the Administrator at 3:00 p.m. and conducted a telephonic interview with the Administrator, two staff, a Los Angeles Fire Department personnel (LAFD), and requested copies pertinent documents.


...Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
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 3
Control Number 29-AS-20201123113645
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 VIEW ASSISTED LIVING
FACILITY NUMBER: 197610004
VISIT DATE: 05/18/2022
NARRATIVE
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...Continued from LIC 9099...

It was alleged that there was an absence of supervision and that facility staff are not fingerprint cleared and/or associated to the facility. It was reported that LAFD responded to an emergency call and arrived at 7:56 p.m. Additionally, the LAFD remained on scene until a staff member arrived at the facility at 8:20 p.m. Record review revealed that Individual #1 (I1) developed a medical emergency on 11/22/2020 and was found to be anxious and hyperventilating and in a room that appeared to be used by an employee. When I1 was asked if they were an employee, I1 stated they were not a worker but a family member of the owner and was only there for the night. Also, interviews conducted revealed that I1 had stated there was no other staff in the facility when asked if there were any other workers there. Furthermore, the LAFD waited for another staff to arrive at the facility after I1 was transported to the hospital due to there being no other staff present to care and supervise the residents. When Staff #1 (S1) arrived at the facility, they were asked if they worked at the facility to which S1 stated that they did. S1 was asked if I1 was an employee and S1 stated that I1, ‘’was not a worker, but was asked sometimes to stay the night by the owner’. Additionally, record review of files revealed that there was no staff file for S1. Information gathered revealed that neither S1 nor I1 were associated and/or were listed on the facility’s employee roster. Based on all information gathered during the course of the investigation, the above allegations, “absence of supervision” and “facility staff are not fingerprint cleared and/or associated to the facility” are deemed Substantiated at this time.

A Civil Penalty for $200 will be assessed today. Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC LIC9099-D).



Exit interview conducted. Citation issued. Appeal Rights discussed. A copy of report provided via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20201123113645
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 VIEW ASSISTED LIVING
FACILITY NUMBER: 197610004
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2022
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met as evidenced by:
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The administrator will submit a detailed plan on how they will ensure the facility will always have staff at the facility and submit staff schedule for the previous month and submit to CCL by 5/18/2022.
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Based on interviews and information gathered, the licensee did not comply with the section cited above as they failed to have staff at the facility supervising and caring for residents at all times, which poses an immediate health and safety risk to residents in care.
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Type A
05/18/2022
Section Cited
CCR
87355(e)(1)
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87355(e)(1) Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. Requirement not met as evidenced by:
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The administrator will submit a Statement of Understanding detailing how they will obtain fingerprint clearance for future staff and submit to CCL by 5/18/2022.
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Based on interviews and information gathered, the licensee did not comply with the section cited above as they failed to have staff at the facility fingerprint cleared and/or associated to the facility before caring and supervising residents, which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3