197610004-7-6-2022-29-AS-ECAS-CG3UYG-20220706155956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610004
Report Date: 07/06/2022
Date Signed: 07/06/2022 04:00:44 PM

Document Has Been Signed on 07/06/2022 04:00 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 LIVING		FACILITY NUMBER:	197610004
ADMINISTRATOR:	GASPARYAN, SUSANNA		FACILITY TYPE:	740
ADDRESS:	20565 CALIFA STREET		TELEPHONE:	(747) 226-1408
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6		CENSUS: 3	DATE:	07/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Susanna Gasparyan		TIME COMPLETED:	04:05 PM

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at approximately 1:45 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Susanna Gasparyan and explained the reason for the visit.

The 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: Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: The LPA observed four bedrooms, two bedrooms observed were shared and two were private with one containing a private bathroom and the other with an exit to the exterior. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Restrooms are clean, sanitary and in operating condition with grab bars and non-skid surfaces. The LPA observed appropriate hand-washing signs. Water temperature measured between 108.1 degrees Fahrenheit and 131.5 degrees Fahrenheit at the time of the visit. Administrator used a personal thermometer which read the temperature from a short distance. Temperatures read within department guidelines however would not register temperature over 120 degrees Fahrenheit. Administrator indicated they would replace thermometer to ensure and accurate reading.

Continued on LIC8 09-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

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: 07/06/2022

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COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. Passageways were clean and clear of obstructions. A locked and inaccessible pool was observed in the backyard at the time of the visit. Facility has a designated visitation area located outside under a covered patio area with appropriate furniture and seating for residents. The LPA observed all the required postings in the dining room and the hallway that promoted cough etiquette, signs and symptoms of COVID-19, and appropriate hand hygiene. Medications are kept locked inaccessible in the kitchen area filing cabinet. A medication lock box was observed in the kitchen refrigerator with a key attached and unlocked. Administrator was reminded that medication box is to remain locked and inaccessible at all times. Hand sanitizer was available for staff and resident use. Fire Extinguisher was last bought 5/31/2022.

GARAGE: There is an attached garage containing a laundry room, cleaning supplies, additional Personal Protective Equipment (PPE) and incontinence supplies. The garage was locked with a single latch making it accessible to residents with a single turn. The administrator was reminded that it must be kept locked and inaccessible to residents at all times. The administrator indicated that they would use the dead-bolt to ensure that the garage is kept appropriately secured at all times.

INFECTION CONTROL: The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. The facility can designate a single isolation room if the facility has a confirmed case of COVID-19. The Administrator continues to conduct testing, regardless of vaccination status. The facility’s policies and procedures as it pertains to infection control are adequate.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Licensee. A copy of this report, LIC 809-D, and Appeal Rights were discussed and provided to Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/06/2022 04:00 PM - It Cannot Be Edited

Created By: Elsie Campos On 07/06/2022 at 03:34 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VIEW ASSISTED LIVING	FACILITY NUMBER: 197610004
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as the hot water registered above 120 degrees farenheit, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/15/2022
	Plan of Correction
1 2 3 4	The adminsitrator agreed to do the following: 1. Adjust the water heater no later than today 7/6/22 and advise CCL. 2. Complete a 5 day log of hot water temperature. Submit to CCL no later than 7/15/22.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as accessible medications were observed in the refrigerator, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 07/11/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Secure the medications. Inform the LPA when this has happened, but no later than 7/7/2022. Plan of correction met at time of the visit. 2. Inform the LPA when all staff have been retrained on medication storage guidlines.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Elsie Campos

LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

LIC809 (FAS) - (06/04)

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