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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610004
Report Date: 05/17/2023
Date Signed: 05/17/2023 04:15:02 PM

Unsubstantiated


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
05/20/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-NP-20220520162356
FACILITY NAME:VALLEY VIEW ASSISTED LIVINGFACILITY NUMBER:
197610004
ADMINISTRATOR:GASPARYAN, SUSANNAFACILITY TYPE:
740
ADDRESS:20565 CALIFA STREETTELEPHONE:
(747) 226-1408
CITY:WOODLAND HILLSSTATE: ZIP CODE:
91367
CAPACITY:6CENSUS: 6DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Susanna GasparyanTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Failure to seek timely medical attention.
Facility failed to inform responsible party of a fall.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced subsequent complaint visit to continue the investigation into the allegations noted above and to deliver the findings. LPA met with Administrator Susanna Gasparyan and explained the reason for the visit.

On 05/24/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial 10-day
complaint investigation visit regarding the above allegations. LPA Urena arrived at the facility at 12:30 p.m.
At 1:00 p.m. the LPA and the administrator conducted a brief tour of the facility. At 1:14 p.m., the LPA requested records for review, and conducted staff and administrator interviews from 1:30 to 2:00 p.m. On 5/17/2023 LPA Campos conducted a subsequent visit to deliver findings, condcuted a brief facility tour at 2:40 p.m. and interviwed responsible party at 2:50 p.m.

**Continued on LIC 9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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-NP-20220520162356
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: 05/17/2023
NARRATIVE
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PAGE 2

Facility failed to inform responsible party of a fall

On 5/20/2022, the Department received a complaint regarding the facilities failure to inform responsible party of a fall. It was reported that Resident #1 (R1) had fallen on 4/20/2022 and received a cold pack for wrist pain on the morning of 4/20/2022. R1’s responsible party (RP) arrived at the facility at around 11:00 am at which time they were notified of the incident. R1 did not show any signs of further injury and staff continued to monitor for any changes. Medical records revealed that the RP reported on 4/27/2022 that R1 had two falls at the facility on 4/20/2022 and that evening or following morning on 4/21/2022. It was noted that the RP disclosed that R1 had some swelling, but a cold compress was placed on their wrist and was better with no complaints of pain. At this time RP was aware of the falls and therefore contradicts reports of not being notified.

Based on the information obtained, while this may or may not have happened the Department does not have sufficient evidence to support the above allegations. Therefore, the above allegations are deemed Unsubstantiated at this time.

Failure to seek timely medical attention

On 5/20/2022, the Department received a complaint regarding the facilities failure to seek timely medical attention. It was reported to that Resident #1 (R1) had stumbled and received a cold pack for wrist pain on the morning of 4/20/2022. R1’s responsible party (RP) arrived at the facility at around 11:00 am at which time they were notified of the incident. R1 did not show any signs of further injury and staff continued to monitor for any changes. Medical records revealed that the RP reported on 4/27/2022 that R1 had two falls at the facility on 4/20/2022 and that evening or following morning on 4/21/2022. It was noted that the RP disclosed that R1 had some swelling, but a cold compress was placed on their wrist and was better with no complaints of pain. On 4/29/22 a registered nurse visited R1 at which time it was not noted that R1 had a fracture and R! had no complaints of pain. On 5/3/2022 R1 was sent to the ER for chest pain and high blood pressure at which time there was no report of a fracture and was sent back home.



**Continued on LIC 9099-C**
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-NP-20220520162356
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: 05/17/2023
NARRATIVE
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PAGE 3

On 5/5/2022 R1 was seen by a physical therapist who did not note that R1 had a fracture or reported any pain. On 5/7/2022 R1 was visited by family at which time there were no concerns relating to a wrist fracture. On May 9th R1 was sent to the ER for high blood pressure at which time it was found that R1 had a fractured wrist. The administrator reported that at no time was R1 exhibiting pain or discoloration to their wrist post their falls in April. Pictures of resident on 4/23/2022 do not show bruising or swelling of R1’s wrist. The administrator reported that they conducted daily wellness checks on all residents.

Based on the information obtained, while this may or may not have happened the Department does not have sufficient evidence to support the above allegations. Therefore, the above allegations are deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted with Administrator and report issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3