197603165-3-3-2022-29-AS-DPEA-CCDTTU-20220310140118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 03/03/2022
Date Signed: 03/03/2022 04:31:58 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
04/26/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210426095836

FACILITY NAME:	GLEN PARK AT VALLEY VILLAGE		FACILITY NUMBER:	197603165
ADMINISTRATOR:	PINK TILLMAN		FACILITY TYPE:	740
ADDRESS:	5527 LAUREL CANYON BLVD		TELEPHONE:	(818) 769-6626
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	100	CENSUS: 37	DATE:	03/03/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Janice Pink		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident was sexually abused while in care

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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 4

Control Number 29-AS-20210426095836

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: 03/03/2022

NARRATIVE

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Continued from 9099

Investigator Miles conducted interviews with R1 on 04/28/2021 at approximately 1414 hours, and staff #2 (S2) at approximately 1507 hours; and former caregivers on 07/26/2021 from approximately 1221 hours to approximately 1439 hours. Multiple attempts to contact former caregiver S3 were made on 07/26/2021 and 07/28/2021. On 08/02/2021 at approximately 1251 hours, an interview was conducted with former caregiver S1. Additionally, on 04/28/2021, Investigator Miles obtained a copy of a written statement made by R1.

Information gathered during the course of the investigation revealed that R1 was never touched inappropriately by anyone and S1 never sexually abused or performed oral sex on R1. It was further revealed that former caregivers never witnessed S1 sexually abuse or perform oral sex on R1. S1 further denied the allegation of sexually abusing or performing oral sex on R1. On 07/26/2021, Investigator Miles received and reviewed the Los Angeles Police Department (LAPD) report which summarized that R1 denied the sexual abuse allegation. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegation. Therefore, the above allegation is deemed UNSUBSTANTIATED at this time.

Exit interview, copy of report given.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
04/26/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210426095836

FACILITY NAME:	GLEN PARK AT VALLEY VILLAGE		FACILITY NUMBER:	197603165
ADMINISTRATOR:	PINK TILLMAN		FACILITY TYPE:	740
ADDRESS:	5527 LAUREL CANYON BLVD		TELEPHONE:	(818) 769-6626
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	100	CENSUS: 37	DATE:	03/03/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Janice Pink		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff did not notify appropriate parties of resident's incident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted on 04/27/2021 by LPA Brian Balisi. LPA met with Janice Pink and explained the reason for the visit. It was alleged that facility staff did not notify appropriate parties of resident’s incident. On 04/27/2021 at 10:30 a.m., LPA Brian Balisi conducted the initial complaint visit and toured the facility with Assistant Administrator, Elizabeth Flores. LPA Balisi obtained copies of pertinent documents relevant to the investigation. Additionally, LPA reviewed facility folder located in the Woodland Hills North Adult and Senior Care Office.Information gathered and reviewed revealed that facility did not submit a Special Incident Report (SIR) to Community Care Licensing (CCL) for the incident on 04/23/2021. CCL was notified of the incident from the SOC341 form “Suspected Dependent Adult/Elder Abuse” form submitted by the complainant. Therefore, the above allegation “facility staff did not notify appropriate parties of resident’s incident” is SUBSTANTIATED at this time.
Citation issued, appeal rights given, exit interview conducted.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20210426095836

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: 03/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/04/2022 Section Cited CCR 87211(c)	1 2 3 4 5 6 7	87211(c) Reporting Requirements. Any suspected physical abuse that does not result in serious bodily injury... shall be reported to the local ombudsman, the licensing agency, and the local law enforcement agency within twenty-four (24) hours. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agree to review 87211 Reporting Requirements. Submit memo of understanding regarding reporting requirements, including Mandated Reporting, to CCL via email by 3/4/2022
	8 9 10 11 12 13 14	Based on record review, the licensee did not comply with the section cited above, as facility staff did not fulfill reporting requirements to appropriate parties, including Mandated Reporter requirements by reporting suspected abuse, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4