Totally Kids Specialty Healthcare - Sun Valley
TOTALLY KIDS SPECIALTY HEALTHCARE - SUN VALLEY in SUN VALLEY, CA — inspection on February 23, 2026.
Found 17 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 37's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 1/12/2026, the MDS indicated the resident usually makes herself understood and usually understood others.
The MDS further indicated Resident 37 required supervision (helper provides verbal cues and some touch assistance) with eating, upper body dressing and putting on shoes.
The MDS indicated Resident 37 required partial assistance (helper does less than half the effort) with toileting, bathing, lower body dressing and personal hygiene.
During an observation and interview on 2/20/26 at 7:57 p.m., in the hallway near the entrance of Resident 37's room with LVN 1, LVN 1 was observed entering Resident 37`s room through a closed door, without knocking on the door or asking permission to go in.
Observed Resident 37 standing on the right side of her bed, nearest to the door.
Upon leaving the room, LVN 1 was interviewed and stated that she should have knocked and asked permission prior to entering to ensure Resident 37's privacy and dignity.
During an interview on 2/22/26 at 5:26 p.m. with the Director of Staff Development, (DSD), the DSD stated that anyone entering a resident`s room must knock and ask permission prior to entering the resident`s room.
The DSD stated residents' privacy and dignity should be respected and promoted at all times.
During a review of the facility`s policy and procedure (P&P) titled Resident Rights last reviewed on 12/3/2025, the P&P indicated that the facility shall treat each resident with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs.
During a review of the facility`s policy and procedure (P&P) titled Privacy last reviewed on 12/3/2025 the P&P indicated that the facility would ensure that each resident's right to privacy will be respected.
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
During a review of Residentˆ3's Minimum Data Set (MDS- aˆresident assessment tool)ˆdated 12/18/2025, the MDS indicated Residentˆ3's cognition (a mental processˆofˆacquiringˆknowledge and understanding through thought,ˆexperienceˆandˆthe senses) was severely impaired.
The MDS indicated Residentˆ3ˆwas dependent on staff withˆoral hygiene,ˆtoileting hygiene,ˆand personal hygiene.ˆ During a review of Resident 3's Immunization History Report,ˆthe Immunization History Reportˆindicatedˆthat Resident 3ˆreceived the COVID-19 vaccine onˆ10/16/2025.ˆ
During an interview on 2/22/2026 at 4:09 p.m. with Family Member 1 (FM 1), FM 1ˆstatedˆthat Resident 3 received the COVID-19 vaccineˆwithout FM 1's knowledge. FM 1ˆstatedˆthat FM 1 was informed that Resident 3 received the COVID-19 vaccine only after the vaccine was administered.ˆ During a concurrent interview and record review onˆ2/22/2026ˆatˆ5:14ˆp.m., with theˆDirector of Staff Development (DSD) theˆDSDˆreviewed Residentˆ3'sˆprogress notes from 8/1/2025-10/31/2025.
The DSDˆstatedˆthat thereˆwasˆno documented evidence thatˆFM 1ˆwas informedˆin advance, nor was there documentation that informed consent was obtained prior to the administration of the COVID-19 vaccine.
The DSD statedˆthatˆit is FM 1's right as Resident 3's responsible party to be informed in advance of the vaccine administration so they may provide informed consent and have the opportunity to ask questions.
During aˆreview of the facility's policy and procedureˆ(P&P)ˆtitled, Resident's Rights,ˆwith review date ofˆ12/3/2025, theˆP&Pˆindicated it is the resident's rightˆtoˆbe fully informed,ˆto be fully informed by the physician of his or her total health status and to be affordedˆthe opportunity to participate on an immediate andˆongoingˆbasis in the total care plan of care including the identification of medical, nursing andˆpsychosocialˆneeds and the planning related services.ˆ ˆ During a review of the facility's P&Pˆtitled, Informed Consent,ˆwith review date of 12/5/2025, the P&Pˆindicatedˆthe facility willˆbe responsible forˆassuring the resident's recordˆcontainsˆdocumentation that the resident has given informed consent prior to the implementation of the proposed treatment procedure.ˆˆ 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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
During a review of Resident 1's facility provided audit of the resident's Change of Condition (COC - a record that tracks any new, worsening, or unexpected change in a patient's physical, mental, or functional status) documents, there was no documented COC assessment completed following the lab result of Depakote obtained on 10/10/2025.
During a review of Resident 1's progress notes from 10/10/25 to 2/21/2026, there was no documented evidence that RP 1 was notified of Resident 1's critical Depakote lab value results on 10/10/2025.
During an attempted telephone interview on 2/21/2026 at 12:33 p.m. with RP 1, the call was not answered and a message was left. An attempt to call RP 1 again on 2/21/2026 at 3:45 p.m. was unanswered and was not returned prior to the survey exit.
During a concurrent interview and record review on 2/21/2026 atˆ11:45 a.m. with the Director ofˆStaffˆDevelopmentˆ(DSD), the DSD reviewed Resident 1's COCs, lab results report dated 10/10/2025 and progress notes from 10/10/2025 to 2/21/2026.
The DSD stated the lab results report for Depakote indicated a value >150 mcg/ml and was flagged in red as HH, indicating a dangerously and critically high level.
The DSD stated that a COC should have been completed and that RP1 should have been notified, as RP 1 is responsible for overseeing the resident's care.
During a review of the facility providedˆpolicy and procedure (P&P)ˆtitled, Resident Rights last reviewed on 12/3/2025, the P&Pˆindicatedˆthe facility must ensure resident rights are not violated.
The P&P indicated the resident has the right to be fully informed of their total health status and be afforded the opportunity to participate on an immediate and on-going basis in their total plan of care.
During a review of the facility providedˆP&Pˆtitled, Change of Condition - Resident last reviewed on 12/3/2025, the P&Pˆindicated all occurrences resulting in a resident's change in condition must be documented in the medical records and parent/legal representative will be notified as soon as possible.
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
indicated copies of resident's protected health information (PHI), retained temporarily, are no longer
the facility shall train all member of the workforce on the privacy policies and procedures with
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
During a review of Resident 3's Minimum Data Set (MDS- aˆresident assessment tool)ˆdated 12/18/2025, the MDS indicated Resident 3's cognition (a mental processˆofˆacquiringˆknowledge and understanding through thought,ˆexperienceˆandˆthe senses) was severely impaired.
The MDS indicated Resident 3 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene.ˆ ˆ During a review of Residentˆ3's Immunization History Record, the Immunization History Recordˆindicatedˆthat Residentˆ3ˆwas administered the influenza vaccine and COVID-19 vaccine on 10/16/2025.ˆ ˆ During a concurrent interview and record review on 2/22/2026 at 5:27ˆp.m. with the DSD, the DSD reviewed Residentˆ3's Immunization History Record andˆstatedˆthat Residentˆ3ˆwas administered the influenza vaccine and COVID-19 vaccine on 10/16/2025.
The DSD reviewed Residentˆ3's care plans andˆstatedˆthat Residentˆ3ˆdid not have a care plan specific to the administration of the influenza and COVID-19 vaccines.ˆThe DSD continued toˆstateˆthatˆit important for care plansˆto be developed specifically addressing the administration of the influenza and COVID-19 vaccines because it guides the nursing staff on how to appropriately care for the residents who were administered vaccines.
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
During an observation on 2/21/2026 at 8:55 a.m. in Resident 5's room,ˆobservedˆResident 5'sˆfingernailsˆto be long and untrimmed.ˆ During a concurrent observation and interview onˆ2/21/2026 at 5:33 p.m. with the Director of Staff Development (DSD), in Resident 5's room, the DSDˆobservedˆResident 5's fingernails.
The DSDˆstatedˆthat Resident 5's fingernails are longˆpast fingertips, with sharp and uneven edges.
The DSDˆstatedˆthat Resident 5's fingernails should be trimmed and filed.ˆ b.
During a review of Resident 35's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included congenital malformation (an abnormal, faulty, or imperfectly formed structure of a body part or organ, often present at birth) syndrome, paralysis of vocal cords and larynx (a condition where one or both vocal folds [cords] in the larynx [voice box] cannot move due to damaged nerves), and stenosis of larynx (abnormal narrowing of the voice box which disrupts the flow of air to the lungs and can impair speech and breathing).
During a review of Resident 35's MDS dated [DATE], the MDS indicated Resident 35's cognition was severely impaired.
The MDS indicated Resident 35 required supervision or touching assistance with eating, oral hygiene, toileting hygiene, and independent with personal hygiene.
During an observation on 2/21/2026 at 8:56ˆa.m. in Residentˆ35's room,ˆobservedˆResidentˆ35's fingernails to be long and untrimmed.ˆ During a concurrent observation and interview on 2/21/2026 at 5:34ˆp.m. with the DSD, in Residentˆ35'sˆroom, the DSDˆobservedˆResidentˆ35's fingernails.
The DSDˆstatedˆthat Residentˆ35'sˆfingernailsˆare longer than they should be.
The DSDˆstatedˆthat resident's' nailsˆextended past the fingertips and that the fingernails should be trimmed and filed to for resident safety.
The DSD continued toˆstateˆthat it is the responsibility of all nursing staff to provide nail care to the residents.ˆˆ During a review of the facility'sˆpolicy and procedure (P&P) titled Nail Care, reviewed 12/5/2025, the P&P indicated nail care for residents should be performed weekly and/or as needed by daily/nightly assigned Licensed Nursing Staff (LNS)/Certified Nursing Assistants (CNA).
Fingernails of residents are to be cut as needed.
Length of nail is not to extend past tip of digits.
Nails to be clipped/filed straight across.
Use nail file to gently and carefully clip or file sharp jagged edges.ˆThe designated staff to document time,ˆdate,ˆhow procedure was tolerated,ˆand condition of hands feet and nails
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
During an interview on [DATE] at 5:15 p.m. with RN 1, RN 1 stated she was sorry and she did not know a hands-on component was required for return demonstration and compliance for CPR certification. RN 1 stated the CPR course was completely web-based.
During an interview on [DATE] at 5:34 p.m. with Director of Staff Development (DSD), the DSD stated according to facility policy, all CPR certifications must have a hands-on component to test out what the staff learned and to ensure CPR is performed correctly.
During a review of the facility`s policy and procedureˆ(P&P)ˆtitled Verification of Licenses and/or Credentials Required Certifications last reviewed onˆ[DATE]ˆtheˆP&Pˆindicatedˆthatˆthey would employ only those that have provided proper certifications and shall be maintained and kept current. ˆThe policy indicated a current BLS card is required of all clinical personnel, including registered nurses, and must be renewed every two years.
The policy further indicated BLS classes were offered in person at the facility.
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
During an interviewˆon 2/21/2026 at 5:57 p.m. withˆthe DSD, the DSDˆstatedˆthat Resident 5'sˆsoftˆhelmet did not have a chin strap,ˆwhich madeˆResident 5'sˆsoftˆhelmet ineffective in preventing injury.
The DSD furtherˆstatedˆthatˆdirect care staff should have noticed theˆmissing chin strap and requested a replacement soft helmet from the registered nurses to help prevent injuries.
During aˆreview of the facility's policies and proceduresˆ(P&P)ˆtitled ResidentˆSafety,ˆreviewed12/5/2025,ˆthe P&Pˆindicatedˆallˆthat employees will use safe techniques and procedures while treating residents toˆassure resident safety at all times .ˆensure safety devices are in place as ordered.
Safety devices may include,ˆbut are not limitedˆto:ˆsoft helmet,ˆhard helmet,ˆsafetyˆpadsˆand landing pads
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 5's cognition (a mental process of acquiring knowledge and understanding through thought, experience and senses) was severely impaired.
The MDS indicated Resident 5 required setup or clean-up assistance with eating and substantial/maximal assistance with oral hygiene, toileting hygiene, and required partial/moderate assistance with personal hygiene.
The MDS indicated that Resident 5 is currently in a toileting program (a structured, planned routine designed to help a person [child or adult] gain or regain control over bladder and bowel habits).
During a review of Resident 5's Order Summary Report, the Order Summary Report indicated for bowel and blader training: Place resident on toilet every two (2) hours while awake for 2 minutes.
Certified Nursing Assistants (CNAs) to document method used result.
Order date: 7/7/2025.
During a review of Resident 5's care plan (a document that summarizes a resident's needs, goals, and care/treatment) initiated on 9/3/2025, the care plan indicated Resident 5 is participating in a Bowel & Bladder training program.
Interventions indicated nursing staff to assist resident to the toilet/commode (a portable, chair-like toilet with a removable basin for people with limited mobility) /toddler potty chair every 2 hours while awake and as needed.
Document method used.
During a concurrent interview and record review on 2/21/2026 at 7:00 p.m., with the Director of Staff Development (DSD), reviewed Resident 5's medical records, nursing progress notes and CNA tasks for the month of 1/2026 to present.
The DSD stated that Resident 5 is in a bowel and bladder training program.
The DSD stated that Resident 5 is to be placed on the toilet every two (2) hours to help train Resident 5 to use the toilet.
The DSD stated when staff place Resident 5 on the toilet, staff are to document in Resident 5's medical record.
The DSD stated that there was no documented evidence that Resident 5 was placed on the toilet on the following days: 1/6/2026; 1/10/2026; 1/18/2026; 1/19/2026; 1/20/2026; 1/25/2026; 2/14/2026; 2/15/2026; 2/19/2026; and 2/21/2026.
The DSD continued to state that based on the documentation, staff did not place Resident 5 on the toilet as ordered.
The DSD stated staff should have placed Resident 5 on the toilet every two (2) hours and document their efforts.
The DSD further stated it is important to toilet train Resident 5 because of his age and for his health and well-being.
During a review of the facility's policy and procedure (P&P) titled, Bowel and Bladder Evaluations - Incontinence, reviewed 12/5/2025, the P&P indicated nursing measures will be employed to prevent and reduce incontinence (a problem holding in urine or stool) for each resident.
Licensed Nurse Staff (LNS) to evaluate the residents' performance in the bowel and bladder management program on the weekly summary.
Daily recording of intake and output of all residents unless fully trained.
Review and report at each IDT (Interdisciplinary Team- a group of professionals from different fields who work together closely, sharing knowledge to provide comprehensive care) care plan for appropriate input and output.
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
During an interview onˆ02/21/2026 2:24ˆp.m.ˆwith Registered Nurse 2, reviewedˆResident 22`s care plan (CP) addressing the risk for dehydrationˆdeveloped on 4/24/2024,ˆthe CP included an intervention toˆprovide 170ˆmilliliters (ml) of water via GT pump six times a day for hydration. RN 2ˆstatedˆthat it is important toˆdocument the amount of water administered to the resident to ensure nurses are aware of how much water has been given. RN 2 stated that if the resident does not receive enough water, it may increase the resident's risk for dehydration, which could result in urinary tract infection.
During a review of the facility`s policy and procedure (PP) titled Resident Care Planning, last reviewed on 12/3/2025, the PPˆindicatedˆthat A comprehensive plan of care will be developed to meet each resident`s medical,ˆdevelopmentalˆand psychosocial needs.
This care plan will include the problems/needsˆidentifiedˆin the Resident Assessment Instrument as well as other problems/needs asˆidentifiedˆby the staff,.ˆ During a review of the facility's P&P titled, Enteral Tube Feeding: Gastrostomy ., last reviewed on 12/3/2025, the PP indicated that open system water bags are used when prescribed by the physician.
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
During aˆconcurrent medication administration observation and interview onˆ02/21/2026ˆatˆ5:04ˆp.m.,ˆwith LVN 4, observedˆLVN 4 prepareˆ Miralaxˆby mixing it (Miralax) with 60ˆml of water. LVN 4ˆdonned gloves, gown and mask andˆproceeded to Resident 1's bedside.ˆ LVN 4 turned off Resident 1's enteral feeding pump, flushed the G-tube with five ml of water, administered Miralax, and flushed the G-tube with five ml of water after administration without verifying the placement of the G-tube.
When LVN 4 was asked about verifying the placement of Resident 1's G-tube, LVN 4 stated she forgot to check the G-tube placement by aspirating for gastric residual to ensure the G-tube was in the stomach.
During an interview onˆ02/21/2026ˆatˆ6:59ˆp.m., withˆRegistered Nurse 2 (RNˆ2), RN 2ˆstatedˆthat prior to medication administration via G-tube, the nurse should check theˆplacement by aspirating for gastric contents. RN 2ˆstatedˆthat if the G-tube is not in the stomach,ˆthe medications canˆseepˆinto the abdominal cavity and causeˆinfectionˆand trauma.ˆRN 2 further stated it is important to check G-tube placement to prevent aspiration pneumonia.
During a review of the facility`s policy and procedure (PP) titled Medication Administration, last reviewed on 12/3/2025, the PP indicated that Medication Administered Via An Enteral Feeding Tube General Guidelines.Check enteral tube for placement using a syringe to administer an air bolus, while auscultating, then aspirate stomach contents, noting residual and removing previously inserted air.ˆ
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
During an interview on 2/23/2026 at 8:13 a.m. with the Infection Preventionist (IP), the IPˆstatedˆthat a COVID-19 clinic comes to the facility and the clinic's pharmacist administers the COVID-19 vaccine to the residents and that licensed nurses do not administer the COVID-19 vaccine to the residents in the facility.
The IPˆstatedˆthat she was not aware that there were no orders to administer COVID-19 vaccine to Resident 5, Resident 35, and Resident 3.
The IPˆstatedˆthat she did not obtain physician orders for the COVID-19 vaccine prior to the administration of the COVID-19 vaccine by the clinic pharmacist.
During a follow up interview on 2/23/2026 at 8:45 a.m. with the IP, the IPˆstatedˆthat it is important to obtain a physician's orders for the administration of anyˆvaccineˆto ensure resident safety.
During a concurrent interview and record review on 2/23/2026 atˆ9:45ˆa.m. with theˆMRD,ˆthe MRD reviewed Resident 3's active and discontinued physician's orders andˆstatedˆthat there was no order to administer the COVID-19 vaccine to Resident 3.
During a review of the facility's policy and procedure (P&P) titled Medication Administration, review date 12/5/2025, the P&P indicated that physician ordered medication to be administered by licensed medical/nursing personnel using the six rights of medication administration:ˆThe rightˆresident,ˆdose,ˆamount,ˆtime,ˆroute,ˆand rationale.ˆAll medication to be administered following the proper guidelines and techniques: a.ˆCheck order on medication record with label on prescribed medication for proper resident name,ˆmedication,ˆdosage,ˆtime,ˆroute,ˆand rationale.ˆ
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
LNS (Registered Nurses or Licensed Vocational Nurses - not CNAs) and documented in PCC
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
serve food in accordance with professional standards.
and six large-sized boxes of drinks and food items were not stacked higher than 18 inches from the
sprinkler clearance to reach the top of these boxes in the event of a fire and the potential for the boxes to fall and dent resulting in harmful bacteria growth for six of 37 medically compromised and vulnerable residents who received food from the kitchen.
Findings: During an initial kitchen observation on 2/20/2026 at 6:15 p.m., observed in the dry storage area, seven medium-sized and six large-sized boxes on two different wire racks that were stacked greater than 18 inches from the ceiling. ˆˆ During a concurrent observation and interview on 2/21/2026 at 11:25 a.m., in the dry food storage area of the kitchen with the Dietary Supervisor (DS), the DS stated it is against the facility's policy to stack items greater than 18 inches from the ceiling and stated there were about 13 boxes total that were stacked greater than 18 inches.
The DS stated there must be at least 18 inches for the water sprinkler on the ceilings to reach and put out a fire.
The DS stated the boxes could also fall causing dents which could lead to bacteria grow.
The DS stated the boxes must be stored correctly as soon as they get delivered. ˆ During a reviewˆof the facility'sˆpolicy and procedure (P&P)ˆtitled,ˆ Food Storage/Preparation, last reviewed on 12/3/2025,ˆthe P&Pˆindicatedˆthe facility must store and secure food safely. ˆ
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
be brought and taken away by a special collection vehicle, or to a bin that a specially designed
used. 2.
Ensure there were no soiled gloves on the floor area and surroundings of the facility's dumpster.ˆ This deficient failure had potential to attract birds, flies, insects, pests, and possibly spread infection to 37 of 37 facility residents.
Findings:ˆ ˆ During an observation on 2/21/2026 at 11:32 a.m., of the facility dumpster area with the Dietary Supervisor (DS),ˆobserved two blackˆdumpstersˆand one blue dumpster fully openˆand a pair of soiled gloves on the ground near the dumpsters.ˆˆˆ ˆˆ
During an interview on 2/21/2026 at 11:34 a.m.,ˆwith the DS, the DSˆstatedˆall the trash must be inside the dumpster and dumpster lids shouldˆalways be closed.ˆThe DSˆstatedˆthe lids on the dumpsters must be closed and the area around the dumpsters must be cleaned and free of trash for infection control and to avoid animalsˆand pestsˆfrom gettingˆinto the trash.ˆThe DSˆstatedˆanimals and pests could come inside the facility and contaminate the food residents would receive.
The DSˆfurther stated theˆdietary departmentˆis responsible forˆkeeping the dumpster lid closed.ˆ During a reviewˆof the facility'sˆpolicy and procedure (P&P)ˆtitled,ˆ Disposal of Infectious and Ordinary Waste Products, last reviewed on 12/3/2025,ˆthe P&Pˆindicatedˆthe facility will ensure all waste products will be disposed of properly and dumpster lids will be closed after every use.
During an interview on 2/22/2026 at 3:21 p.m., with the MRD, the MRD stated
sent to all residents' responsible parties through regular mail and there is no mail confirmation that
does not have any documentation that residents' responsible parties received influenza vaccine information.
During a concurrent interview and record review on 2/22/2026 at 5:24 p.m., with the DSD, reviewed Resident 35's Immunization History Record.
The DSD stated that Resident 35 was administered the influenza vaccine on 10/16/2025.
The DSD reviewed Resident 35's nursing progress notes and social services progress notes from 8/2025-10/2025 and stated that there was no documented evidence that Resident 35's responsible party received influenza vaccine information prior to the administration of the influenza vaccine. c.
During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 7/24/2024 with diagnoses that included cerebral palsy (a group of lifelong disorders affecting body movement, muscle tone, and posture caused by abnormal brain development or damage, usually before birth), tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the windpipe) status, persistent vegetative (a condition where, following severe brain damage, a person is awake but shows no signs of awareness, thought, or purposeful reaction to their environment), dependence on respirator (ventilator- a medical machine that helps a patient breathe or completely takes over their breathing when they cannot do so on their own) status.
During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was severely impaired.
The MDS indicated Resident 3 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene.
During a review of Resident 3's Immunization History Record, the Immunization History Record indicated that Resident 3 was administered the influenza vaccine on 10/16/2025.
During an interview on 2/22/2026 at 2:41 p.m., with the IP, the IP stated that the IP does inform residents' responsible parties to provide education about the influenza vaccine.
The IP stated that it is the responsibility of the medical records department to provide influenza vaccine information.
During an interview on 2/22/2026 at 3:21 p.m., with the MRD, the MRD stated that the MRD sends influenza vaccine information to residents' responsible parties to provide education about the influenza vaccine.
The MRD stated that the influenza vaccine information was sent to all residents' responsible parties through regular mail and there is no mail confirmation that residents' responsible parties received the information.
The MRD continued to state that the MRD does not have any documentation that residents' responsible parties received influenza vaccine information.
During a concurrent interview and record review on 2/22/2026 at 5:27 p.m., with the DSD, reviewed Resident 3's Immunization History Record.
The DSD stated that Resident 3 was administered the influenza vaccine on 10/16/2025.
The DSD reviewed Resident 3's nursing progress notes and social services progress notes from 8/2025-10/2025 and stated that there was no documented evidence that Resident 3's responsible party received influenza vaccine information prior to the administration of the influenza vaccine.
During an interview on 2/23/2026 at 8:13 a.m., with the IP, the IP stated that it important to provide residents' responsible parties with vaccine information so that the residents' responsible parties will know the risk and benefits of the vaccine and they also have the right to be informed.
During a review of the facility's policy and procedure (P&P) titled, Immunization, review date 12/5/2025, the P&P indicated Social Service staff and/or IP to provide parent/legal representative with Vaccine Information Sheet(s) when indicated.
Document when the Information Sheet(s) were provided.
Vaccine information sheet can be given at anytime prior to the vaccine being administered.
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Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352
During an interview on 2/22/2026 at 3:21 p.m., with the MRD, the MRD stated that the MRD
responsible parties through regular mail and there is no mail confirmation that residents' responsible
documentation that residents' responsible parties received COVID-19 vaccine information.
During a concurrent interview and record review on 2/22/2026 at 5:24 p.m., with the DSD, reviewed Resident 35's Immunization History Record.
The DSD stated that Resident 35 was administered the COVID-19 vaccine on 10/16/2025.
The DSD reviewed Resident 35's nursing progress notes and social services progress notes from 8/2025-10/2025 and stated that there was no documented evidence that Resident 35's responsible party received COVID-19 vaccine information prior to the administration of the COVID-19 vaccine. c.
During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 7/24/2024 with diagnoses that included cerebral palsy (a group of lifelong disorders affecting body movement, muscle tone, and posture caused by abnormal brain development or damage, usually before birth), tracheostomy (a surgical procedure that creates an opening in the neck leading directly into the windpipe) status, persistent vegetative (a condition where, following severe brain damage, a person is awake but shows no signs of awareness, thought, or purposeful reaction to their environment), dependence on respirator (ventilator- a medical machine that helps a patient breathe or completely takes over their breathing when they cannot do so on their own) status.
During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was severely impaired.
The MDS indicated Resident 3 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene.
During a review of Resident 3's Immunization History Record, the Immunization History Record indicated that Resident 3 was administered the COVID-19 vaccine on 10/16/2025.
During an interview on 2/22/2026 at 2:41 p.m., with the IP, the IP stated that the IP does inform and provide education to residents' responsible parties about the COVID-19 vaccine.
During an interview on 2/22/2026 at 3:21 p.m., with the MRD, the MRD stated that the MRD sends COVID-19 vaccine information to residents' responsible parties to provide education about the COVID-19 vaccine.
The MRD stated that the COVID-19 vaccine information was sent to all residents' responsible parties through regular mail and there is no mail confirmation that residents' responsible parties received the information.
The MRD continued to state that the MRD does not have any documentation that residents' responsible parties received COVID-19 vaccine information.
During a concurrent interview and record review on 2/22/2026 at 5:27 p.m., with the DSD, reviewed Resident 3's Immunization History Record.
The DSD stated that Resident 3 was administered the COVID-19 vaccine on 10/16/2025.
The DSD reviewed Resident 3's nursing progress notes and social services progress notes from 8/2025-10/2025 and stated that there was no documented evidence that Resident 3's responsible party received COVID-19 vaccine information prior to the administration of the COVID-19 vaccine.
During an interview on 2/23/2026 at 8:13 a.m. with the IP, the IP stated that it important to provide residents' responsible party with vaccine information so that the residents' responsible party will know the risk and benefits of the vaccine and they also have the right to be informed.
During a review of the facility's policy and procedure (P&P) titled, Immunization, review date 12/5/2025, the P&P indicated Social Service staff and/or IP to provide parent/legal representative with Vaccine Information Sheet(s) when indicated.
Document when the Information Sheet(s) were provided.
Vaccine information sheet can be given at anytime prior to the vaccine being administered.
555815 02/23/2026
Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352