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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 12/21/2021
Date Signed: 12/21/2021 04:36:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GLEN PARK AT VALLEY VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:PINK TILLMANFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 34DATE:
12/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Elizabeth FloresTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Elsie Campos and Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20211217161220.

During a visit conducted on 12/16/2021, it was observed that Staff #1 (S1) was not associated to the facility, and a file review confirmed that S1 started working at this facility on or about 08/04/2021. A civil penalty was issued on 12/16/2021, noting that S1 could not return to the facility until the association was complete. During today's visit, S1 was observed to be working at this facility. The LPAs reviewed the Caregiver Background Check System during today’s visit and observed that S1 was not associated to this facility. Per the staff schedule, S1 worked on 12/17/2021, 12/18/2021, and today, 12/21/2021.

At the start of the visit, the LPAs observed the posted Administrator Certificate for the Administrator Pink Tillman III (#6009095740) to be expired. The LPAs checked the Administrator Application Status online and did not observe the Administrator’s name on either the active or pending list. Throughout the visit, the LPAs observed signs alerting staff and residents that ‘Janyce Pink’ was the new Assistant Administrator, effective immediately. However, S2 is not associated to this facility, nor does the Department have any paperwork, designating S2 as an Administrator. An internal file review revealed that this facility sent in an LIC9182 Caregiver Background Transfer Request on 12/20/2021. However, this facility did not include a completed LIC508 Criminal Record Statement or clear copy of S2s ID to complete the association. The date of employment on the association document was 11/23/2021. As of today, S2 is fingerprint cleared but is not associated to this facility. Interviews revealed that S2 began working in this facility on or about BLANK.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted, today's reports and appeal rights were issued. Civil penalties assessed.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE
FACILITY NUMBER: 197603165
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2021
Section Cited

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87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above, as S1 and S2 have not been associated to the facility, which which poses an immediate health and safety risk to residents in care.
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Type B
12/31/2021
Section Cited

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874069A) Administrator Certification Requirements. (a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator.
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above, as the current Administrator Certificate for the current Administrator on file is expired, which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021
LIC809 (FAS) - (06/04)
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