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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 12/21/2021
Date Signed: 12/21/2021 04:45:10 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2021 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20211217161220
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
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Elizabeth FloresTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Illegal Eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Elsie Campos and Ashley Smith arrived unannounced for an initial 10-day complaint visit. The LPAs met with Office Manager Elizabeth Flores and explained the reason for the visit.

During today’s visit, the LPAs spoke to staff at 11:40 a.m. and 11:58 a.m.; spoke to residents at 12:21 p.m., 1:21 p.m., 1:23 p.m., 1:29 p.m.; 1:40 p.m. and 1:45 p.m. In addition, the LPAs reviewed documents pertinent to the investigation.

Cont. on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20211217161220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/21/2021
NARRATIVE
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Regarding the above allegation, it was alleged that Resident #1 (R1) received an illegal eviction notice. Interviews with staff and R1 revealed that R1 was served an eviction notice on 12/16/2021. However, the eviction notice was dated as being issued on 12/2/2021, and the effective date was 1/02/2022. As such, R1 was not allotted a full thirty (30) days to vacate as required by law. Lastly, the eviction notice did not include language as specified in Health and Safety Code Section 1569.683(a)(4), nor did it include information for R1 to file a complaint with the licensing agency or the State Long Term Care Ombudsman office. Based on the information obtained, this allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted, today's reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20211217161220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
12/22/2021
Section Cited
CCR
87224(a)
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87224(a) Eviction Procedures. The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required…
This requirement is not met as evidenced:
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Administrator agreed to do the following:
1.Rescind the eviction notice within the next 24 hours. This must be done in writing. Submit proof to CCL by 12/22/2021 2.Create a valid eviction notice for R1 and submit the eviction notice to CCL for prior approval. Notice must be completed no later than 12/31/2021.
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Based on interview and record review, the licensee did not comply with the section cited above, as the issued eviction notice to R1 was invalid, which poses an immediate 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: Elsie CamposTELEPHONE: (747) 230-3909
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
LIC9099 (FAS) - (06/04)
Page: 3 of 3