VALLEY VILLAGE SENIOR LIVING, INC.

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed in Section 87468.1… (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days… This requirement was not met as evidenced by: Based on interviews the Licensee did not comply with the above cited section in R1’s Responsible Person was not provided all of R1’s records which poses/posed a potential personal rights risk to persons in care.

Official plan of correction

The Licensee will provide R1's Responsible Person with R1's entire file and provide proof to CCLD by POC due date.

Deadline recorded: Aug 28, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in one resident's medication was not administered as prescriebd which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/08/2026 Plan of Correction The Licensee will contact the pharmacy to clarify medication instructions and provide staff training on medication administration. The Licensee will provide proof to CCLD by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in the blinds on Bedroom #1's exit door was in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/21/2026 Plan of Correction The Licensee will repair the blinds and send proof to CCLD by POC due date.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in a resident's discarded medication was not documented on the destruction record which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/21/2026 Plan of Correction The Licensee will provide staff training on medication documentation and provide CCLD proof by POC due date.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in the facility did not have an emergency water supply which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/08/2026 Plan of Correction The Licensee will obtain 72 hours worth of emergency water and send proof to CCLD by POC due date.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by: Based on record review, observation, and interview, the licensee did not comply as two (2) out of three (3) staff members observed at the facility did not have a transfer of criminal record clearance which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator stated he will associate the two staff members by the due date and submit proof to CCLD.

Deadline recorded: May 1, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file... This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited as Resident #1 (R1)'s medications did not have physician's orders on file which posed an immediate health and safety risk.

Official plan of correction

Administrator stated he will obtain the written physician's orders residents medications and will provide proof to CCLD by the due date.

Deadline recorded: May 1, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply as Resident #1 (R1)'s centrally stored medication and destruction record (CSMDR) was not up to date which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator stated he will audit the CSMDRs for the current residents and will submit a signed statement of understanding of the section cited to CCLD by the due date.

Deadline recorded: May 1, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

(i) Prescription medications which are not taken with the resident upon termination of services...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record... This requirement is not met as evidenced by: Based on interview, record review, and observation, the licensee did not comply as R1's medications were not properly destroyed nor documented upon their termination of services which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator destroyed R1's medication during the visit. Administrator will submit a signed statement of understanding including staff signatures to CCLD of the section cited by the due date.

Deadline recorded: May 1, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements (a) Each licensee shall furnish...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by: Based on record review and observation, the licensee did not comply as incident and death reports for Resident #1 (R1) were not submitted to the Department which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator stated he will submit R1's incident and death report to the Department. Administrator will also submit a signed statement of understanding of the section cited to CCLD by the due date.

Deadline recorded: May 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 6 residents did not have their PRN medications recorded when they were administered which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2025 Plan of Correction The Licensee will discuss proper medication documentation with Staff and send CCLD a Statement of Understanding with Staff and Licensee signatures by POC due date.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 6 residents did not have a PRN Authorization Letter and 1 resident had 1 out of 2 PRN Medications listed on their Authorization Letter which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2025 Plan of Correction The Licensee will obtain updated PRN Authorization Letters for 2 residents and send CCLD proof by POC due date.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in that the facility did not have a Plan of Operation on file and was not updated to outline the use of exterior and common area cameras which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2025 Plan of Correction The Licensee will send CCLD an updated Plan of Operation and maintain a copy on file at the facility by the POC due date.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 4 out of 6 residents did not have a Pre-Placement Appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2025 Plan of Correction The Licensee will evaluate the 4 residents with their families and complete an Appraisal, and maintain it annually. The Licensee will send CCLD the completed Appraisals by POC due date.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 6 residents did not have a Medical Assessment and TB test which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2025 Plan of Correction The Licensee will obtain a Medical Assessment and TB test, and send CCLD the reports by POC due date.

Official classification

Type A

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: … (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: … This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in 5 out of 6 residents did not have a Centrally Stored Destruction and Medication Record (CSDMR) which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2025 Plan of Correction The Licesee will obtain CSDMR from the pharmacy, or create their own and send CCLD the records by POC due date.

Official classification

Type B

Official code

87303(e)(4)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that suction grab bars in 2 (two) out of 2 (two) bathrooms were loose and not functioning properly which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/02/2024 Plan of Correction Administrator agrees to purchase new suction grab bars and install them. Administrator also plans to install steel grab bars in the near future. Administrator will send proof of new grab bars to CCL by 08/02/2024.

Official classification

Type B

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Deficient Practice Statement Based on medication review, the licensee did not comply with the section cited above in which PRN medications for 3 (three) out 3 (three) residents were not properly documented which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/02/2024 Plan of Correction Administrator agrees to start using a separate form to document when PRN medications are administered and by which staff members. Administrator agrees to send proof of appropriate forms to CCL by 08/02/2024.

Official classification

Type B

Official code

87705(h)

Regulation authority

CCR

What the official deficiency says

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that the outside exit door does not self-close which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2024 Plan of Correction Administrator agrees to install a spring to the exit door for it to self-close. Administrator will email either a picture of the completed repairs or a quote for the repair/installation to CCL by 08/09/2024.

Official classification

Type B

Official code

87216(a)(1)

Regulation authority

CCR

What the official deficiency says

Bonding: Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.(1)The amount of the bond shall be in accordance with the following schedule: Total Safeguarded Per Month Bond Required: $750 or less -$1,000, $751 to $1,500.- $2,000, $1,501 to $2,500 - $3,000 Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond. The facility does not have a surety bond for R1's SSI funds

Official plan of correction

Licensee will purchase a Surety Bond in the amounts that will cover all resident funds handled by the facility. Evidence of an active Surety Bond will be provided to the Department by no later than 1/16/24

Deadline recorded: Jan 16, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

Personal Rights: (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. Resident#1 who is determined to be able to leave facility unassisted, is not allowed to leave the facility un-supervised until today

Official plan of correction

Licensee will ensure that the residents are allowed to leave the facility unsupervised if they have been determined by their physician to be able to leave the facility unassisted. Provide a written and signed plan of action that the facility will implemement to ensure that residents are allowed to leave the facility by 1/9/24

Deadline recorded: Jan 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as R1's LIC 602 indicated bedridden status, living in a non-ambulatory room, Room #3, Room #1 is cleared for bedridden only, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/24/2023 Plan of Correction Administrator contact family representative to arrange to move of R1 into Room #1 immediately or have R1 move out. Administrator will submit a written statement to CCL once proper changes have been made.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on medication audit, the licensee did not comply with the section cited above as 6 out of 6 residents medication pill count was not concurring with documention, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/24/2023 Plan of Correction Administrator will conduct a medication audit on all 6 resident medications. Administrator will submit a letter to CCL indicating the audit was completed.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited aboveas 6 out of 6 resident did not have their Need and Service/Appraisals, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/11/2023 Plan of Correction Administrator will communciate will resident's representative and have the Appraisal signed. Administrator will submit documentation to CCL.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as R2 did not have their TB test results, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/11/2023 Plan of Correction Administrator will have R2 tested for TB. Administrator will submit results of test to CCL.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above as 6 out of 6 resident did not have an updated Centrally Stored Medication and Destruction Record, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/11/2023 Plan of Correction Administrator will update all 6 residents Centrally Stored Medication Administration Record and submit to CCL.

Official classification

Type B

Official code

87465(d)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as 6 out of 6 residents did not have their PRN Authorization Letter, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/11/2023 Plan of Correction Administrator will sent the PRN Authorization Letter to physicians. Administrator will submit documents, when completed, to CCL.