197603165-2-4-2021-31-AS-NGID-C9QN4A-20211215090732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 02/04/2021
Date Signed: 02/04/2021 02:37:24 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
02/19/2020 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20200219141501

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:	02:00 PM
MET WITH:	Elizabeth Flores (Assistant Administrator)		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Facility did not follow admission agreement regarding the use of third-party services.

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 on 2/16/2020 resident #1 (R1) was taken to Sherman Oaks hospital instead of Kaiser hospital due to R1 being covered by Kaiser. Interviews were conducted with facility staff and R1's responsible person. Information gathered from interviews revealed that emergency services were contacted for R1 and the facility did not make a decision or have a choice of which hospital R1 would be taken to. Emergency personnel was given R1's medical information and made the determination to which hospital R1 went to. Based on the information obtained through interviews 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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