Health inspection·December 6, 2024

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Complaint Number: CA00924286. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for the Complaint Number: CA00924286 (Refer to F837).

F837 SS=D Governing Body CFR(s): 483.70(d)(1)-(3)

F837 11/18/2024 §483.70(d) Governing body. §483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and §483.70(d)(2) The governing body appoints the administrator who is(i) Licensed by the State, where licensing is required; (ii) Responsible for management of the facility; and (iii) Reports to and is accountable to the governing body. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to: 1. Ensure the designated Administrator (DADM) held a current and active license from LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9LN11 Facility ID: CA920000085 If continuation sheet 1 of 5 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055443 (X3) DATE SURVEY COMPLETED 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST VALLEY POST ACUTE 7057 Shoup Ave West Hills, CA 91307 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the State to serve in the capacity of a nursing home administrator (NHA) 2. Implement its policy and procedures (P&P) for ensuring the background check of the DADM was initiated and completed prior to employment. This deficient practice resulted in DADM operating the facility with an inactive NHA licensed that could potentially negatively affect the facility's functions. Findings: 1. During a review of the DADM's employee file, the DADM's employee files indicated the following: a) The DADM's Notice to Employee indicated that the DADM's start date at the facility as 9/9/2024. b) The DADM signed for the administrator job description on 9/9/2024, that included, "Must maintain licensing credentials for an Administrator." During a review of the undated facility's Department Heads 2024 listing submitted to the surveyor on 10/22/2024, the Department Heads listing indicated the DADM's title as "Administrator" of the facility. During a review of the DADM's NHA license verification through the California Department Public Health (CDPH) Licensing and Certification (L&C) Verification Search Page on 10/23/2024 timed at 7:15 a.m., the L&C indicated that there was no data found indicating that DADM had an active and current NHA license. During an interview on 10/22/2024 at 4:55 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9LN11 Facility ID: CA920000085 If continuation sheet 2 of 5 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055443 (X3) DATE SURVEY COMPLETED 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST VALLEY POST ACUTE 7057 Shoup Ave West Hills, CA 91307 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with the Director of Nursing (DON), the DON stated that the DADM's NHA license was still pending and that the DON was unable to verify the DADM's NHA license on the CDPH L&C verification page. The DON stated that the DON was not involve in a hiring process of the Administrator, and that the DADM introduces herself (DADM) as the Administrator upon starting the job on 9/9/2024. The DON further stated that the DADM has since starting the job on 9/9/2024, actively performing the Administrator job tasks. During a review of the undated facility's Department Heads 2024 submitted to the surveyor on 10/23/2024, indicated, the DADM's title was changed from "Administrator" to "Operations Manager". During a concurrent interview and record review on 10/23/2024 at 1:12 p.m. with the DADM, the DADM stated that she (DADM) was hired as the Operations Manager of the facility starting on 9/9/2024. DADM stated that the facility's Executive Director (ED) hired her (DADM). The DADM stated that the ED knew that the DADM's license was not currently active at the time of hire. The DADM stated that she (DADM) was not hired as the Administrator of the facility. When the DADM was asked when was the last time the facility Administrator (ADM) was at the facility, DADM stated that she (DADM) has yet to see the ADM at the facility since being hired on 9/9/2024. When requesting the DADM's job description, the DADM submitted the Job Description for Operations Manager without the DADM's signature. The Job Description indicated the following: - "Must maintain licensing credentials for an Administrator." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9LN11 Facility ID: CA920000085 If continuation sheet 3 of 5 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055443 (X3) DATE SURVEY COMPLETED 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST VALLEY POST ACUTE 7057 Shoup Ave West Hills, CA 91307 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 10/23/2024 at 2:51 p.m. with the Director of Staff Development (DSD), the DSD reviewed the DADM's employee file and stated that the DADM's official hire date was 9/9/2024. The DSD further stated that the DADM signed on the job description for an Administrator on the day of hire on 9/9/2024. During a review of the facility's P&P titled, "Administrator" last revised 8/2024, the P&P indicated, "A licensed administrator is responsible for the day-to-day functions of the facility. In the absence of the administrator, the assistant administrator or director of nursing services is authorized to act in the administrator's behalf .... A complete outline of the administrator's duties and responsibilities is contained in his/her job description." During a review of the facility's Job Description for Administrator prepared by HR dated 12/2028 and signed by the DADM on 9/9/2024, the Job Description indicated, "The primary purpose of your job position is to direct the dayto-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facility to assure that the highest degree of quality care can be provided to our residents at all times .... Must maintain licensing credential for an administrator." During a review of the facility's P&P titled, "Hiring" last reviewed on 6/26/2024, the P&P indicated, "This facility provides an equal employment opportunity to all persons qualified to perform the essential functions of the position that is to be filled .... The following criteria will be considered in determining whether an applicant is qualified for a particular job position .... Certifications and Licenses." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9LN11 Facility ID: CA920000085 If continuation sheet 4 of 5 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055443 (X3) DATE SURVEY COMPLETED 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEST VALLEY POST ACUTE 7057 Shoup Ave West Hills, CA 91307 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. During a review of the DADM's employee file, the DADM's employee files indicated the following: a) The DADM's Notice to Employee indicated that the DADM's start date at the facility as 9/9/2024. b) The DADM's Background Screening Report indicated, the background check was requested on 9/18/2024 and completed on 9/19/2024. During an interview on 10/23/2024 at 2:51 p.m. with the Director of Staff Development (DSD), the DSD reviewed the DADM's employee file and stated that the DADM's official hire date was 9/9/2024. The DSD stated that the facility human resources (HR) was in charge for background checks with a new hiring. The DSD stated that the DADM's Background Screening Report indicated that the background check was requested on 9/18/2024 and completed on 9/19/2024 after the DADM hire date of 9/9/2024 . The DSD stated that the DADM's background check should have been completed prior to employment as per the facility P&P. During a review of the facility's P&P titled, "Background Screening Investigations" last reviewed on 6/26/2024, the P&P indicated, "Our facility conducts employment background screening checks, reference checks and the criminal conviction investigation checks on all applicants for positions with the direct access to residents .... Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9LN11 Facility ID: CA920000085 If continuation sheet 5 of 5