Valley Village Senior Living, Inc.

(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.

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.

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.

(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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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

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.

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.

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.

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.

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.

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.