197603165-5-22-2021-31-AS-CHAS-C4GM2U-20210630091407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 05/22/2021
Date Signed: 05/22/2021 12:30:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/18/2019 and conducted by Evaluator Yelena Avetisyan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20190418102037

FACILITY NAME:	GLEN PARK AT VALLEY VILLAGE		FACILITY NUMBER:	197603165
ADMINISTRATOR:	PINK, JR, TILLMAN		FACILITY TYPE:	740
ADDRESS:	5527 LAUREL CANYON BLVD		TELEPHONE:	(818) 769-6626
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	100	CENSUS: 35	DATE:	05/22/2021
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Jessyca Munoz - Med-Tech		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to provide a safe environment for resident resulting in multiple falls causing injury
Staff failed to keep resident’s room in good repair.
Facility does not meet the hygiene needs of resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with Met Tech Jessyca Munoz who contacted the office Manager Priscilla Pinedo. LPA spoke with the office Manger who designated the med-tech to sign the report. Ms. Pinedo also provided the LPA and email address for the report to be sent to.

Regarding the allegation of " Staff failed to provide a safe environment for resident resulting in multiple falls causing injury" it was alleged that Resident 1 (R1) sustained 2 serious falls in the facility. On 4/26/2019 LPA P. Shanahan conducted interview with R1 who stated that the fall in her room was due to her tripping on some boxes that she forgot that she had placed near her bed. According to R1 the second incident occurred when she tried to squeeze past the housekeeping cart by her door causing her to trip and sustain a broken arm. On 2/27/2020 LPA conducted interview with R1’s responsible party. (RP). According to RP R1 sustained a fall at the facility due to having boxes of puzzles stacked up near her bed, however when the fall occurred staff moved the boxes to a different area. Neither R1 or R1’s responsible party report that R1’s falls were a result of staff failing to provide a safe environment. However, R1’s RP was concerned when re-modeling was taking place at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2021

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 31-AS-20190418102037

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE	FACILITY NUMBER: 197603165
	VISIT DATE: 05/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Per RP the floors were different heights in several areas of the facility and there weren’t any signs to warn residents. When interviewed assistant administrator stated that they provided notices to the residents and their responsible parties of the work taking place and had signs posted near any where work was taking place. Copy of the notice that was given to residents and/or their responsible parties was provided to the LPA via email on 3/13/2020. Based on the information obtained during the course of the investigation the allegation is Unsubstantiated at this time.

Regarding the allegation of Staff failed to keep resident’s room in good repair it was alleged that Resident 1 (R1’s) room ceiling was leaking during the rain season and the facility did not address the situation. When interviewed complainant was unable to provide dates as to when the leak started, when it was reported to the staff and when R1 was moved. On 4/26/2020 LPA P. Shanahan conducted interview with administrator Alin Astrvazadrian and Resident 1 (R1). Per administrator they moved the residents out from their rooms while the ceiling repair was completed. LPA Shanahan was give a tour of the repaired room. When interviewed R1 confirmed that there was a leak in her room. Additionally R1 was moved to a different room while the repairs were taking place. R1 did not share any concerns about the leak in the room or staff response. On 2/27/2020 LPA conducted interview with R1’s responsible party. According to the responsible party the facility changed R1’s room, however she is not sure how long the ceiling was leaking before the move was made. When interviewed on 3/6/2020 assistant administrator stated that R1’s room was changed however he was not able to locate documentation regarding the reason for the move. During the 3/6/2020 LPA requested copy of the facilities maintenance log which were received on 4/30/2020. The maintenance log's did not indicate report of a ceiling leaking. Per Mr. Silva if they receive notification that there is a leak in any resident room, they will notify maintenance who will make sure that the repair is completed. Mr. Silva stated if maintenance is unable to complete the repair, they will move a resident to a different room until the repairs are completed. Based on the information obtained the allegation is unsubstantiated at this time.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20190418102037

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE	FACILITY NUMBER: 197603165
	VISIT DATE: 05/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation of Facility does not meet the hygiene needs of resident it was reported that staff do not assist Resident 1 (R1) with showers. On 2/27/2020 LPA conducted interview with R1’s responsible party (RP). According to the RP when R1’s daughter went to pick up R1 from the facility she smelled of urine. When she asked the facility, they reported that R1 refused showers when staff asked. RP asked for the facility staff to try and motivate R1 and feels that the refusals has lessened. During a subsequent complaint visit conducted on 3/6/2020 LPA conducted interview with assistant administrator who stated that at times R1 would allow the staff to assist with showers and completely refuse at other times. Per administrator the staff documented the refusals. Additionally, staff would keep asking R1 if she would like a shower throughout their shift however staff cannot force R1 or any other resident to do something when they refuse. Administrator submitted copies of the shower refusal log to LPA for review on 3/7/2020. Based on the information obtained the allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3