197603165-2-4-2021-31-AS-NGID-C9QNTA-20211215094426

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 02/04/2021
Date Signed: 02/04/2021 01:02:38 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
02/25/2020 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20200225090656

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: 43	DATE:	02/04/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Elizabeth Flores (Assistant Administrator)		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility not providing services agreed to in admissions agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith finished a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Elizabeth Flores.
Regarding the allegation above it is alleged that the facility would charge resident #1 (R1) to accompany R1 to medical appointments and that it was not agreed to in R1's admission agreement.. Interviews were previously conducted with facility staff and R1's responsible person on 1/26/2020. LPA also reviewed R1's admission agreement. Information revealed that R1 requires assistance going to medical appointments based on their diagnosis. LPA reviewed the facilities policy on transportation which is included in R1's admission agreement and is signed by R1's responsible person. It states if a resident needs an attendant to accompany a resident to a medical appointment then the charge is 25 dollars. Based on the information obtained through record review and admission agreement this allegation is deemed Unsubstantiated at this time. Exit Interview conducted. Copy of report emailed for signature.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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