197603165-3-18-2022-31-AS-CHAS-CCUP7E-20220325110347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 03/18/2022
Date Signed: 03/18/2022 05:48:19 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
02/18/2020 and conducted by Evaluator Yelena Avetisyan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20200218152447

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: 36	DATE:	03/18/2022
		UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Qwutaria Rogers - Office Manager		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff administered incorrect medication resulting in death
Resident sustained multiple injuries due to falls
Resident wandered away from facility
Unqualified staff administering medication
Facility not meeting residents needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yelena Avetisyan conducted an unannounced subsequent complaint visit to the facility to deliver the findings of the allegations listed above.

On 2/18/2020, the complainant reported that approximately one year ago staff incorrectly assisted resident (R1) with medication resulting in death. On 02/20/2020 at 10:15 am, LPA Manya Lefian initiated the complaint in which records were reviewed and interviews with staff were conducted

On 12/15/2021, LPA Avetisyan conducted a departmental file review of all incident and death reports submitted to the department from January 2019 to March 2020. A review of the records identified that the facility reported a death in July 2019. The report indicated that the resident who passed away was on hospice services and the cause of death was reported as respiratory failure.

Cont 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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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Control Number 31-AS-20200218152447

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE	FACILITY NUMBER: 197603165
	VISIT DATE: 03/18/2022

NARRATIVE

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On 12/15/2021 at 8:48 am, LPA Avetisyan requested 911 calls for service records from January 2019 to March 2020. The requested records were received on 12/30/2021. A review of the records revealed that there were no 911 calls made within the requested dates related to resident death and the police did not respond to the facility for a death investigation.

Additionally, on 2/8/2021, LPA Avetisyan conducted interviews with Mr. Rafael Silva who was the Assistant Administrator at the time the complaint was filed with the department. When interviewed, Mr. Silva denied knowledge of any resident passing away as a result of a medication error within the last 2 years. Mr. Silva was aware of an incident where a resident was sent to the hospital due to a medication error, however the resident did not pass away and has since returned to the facility.

On 2/2/2021, 2/3/2021, and 2/7/2021, LPA Avetisyan made phone call attempts in order to obtain identifying death information (name, date of birth, date of death) pertaining to resident (R1), however was unsuccessful.

Due to a lack of supporting information and documentation, LPA Avetisyan was unable to identify R1 and to determine whether R1’s death resulted from the incorrect assistance of medication resulting in death. Therefore the allegations is deemed unsubstantiated at this time.

In regard to allegation # 2 Resident sustained multiple injuries due to falls: it was reported that Resident 2 (R2) sustained 2 falls at the facility 1 of the 2 falls resulted in hospitalization. In regard to the allegation LPA conducted interview with complainant to obtain identifying information for R1 and approximate dates of the incidents, however, was unsuccessful. On 2/8/2021, LPA conducted interview with Mr. Rafael Silva who was the Assistant Administrator at the time the complaint was filed with the department. Per Mr. Silva they have various incidents of residents sustaining falls, some of the falls result in injuries. If a resident is injured due to a fall, they will contact the resident’s family, physician, call 911 if needed and submit an incident report to the department. Due to a lack of supporting information the allegation is Unsubstantiated at this time.

In regard to allegation # 3 Resident wandered away from facility it was reported that Resident 1 (R1) was observed on the side of street when visited family. The family of R1 informed a facility staff of the incident. On 2/2/2021, 2/3/2021 and 2/7/2021 LPA made phone call attempts in order to identify R1, the date of the incident and name of the staff who was notified of the incident. however, was unsuccessful.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200218152447

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE	FACILITY NUMBER: 197603165
	VISIT DATE: 03/18/2022

NARRATIVE

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On 2/8/2021, LPA conducted interview with Mr. Rafael Silva who was the Assistant Administrator at the time the complaint was filed with the department. Mr. Silva could not recall knowledge of an incident where a resident wondered out from the facility and was returned by family. Due to a lack of supporting information the allegation is Unsubstantiated at this time.

In regard to allegation # 4 Unqualified staff administering medication it was reported that unqualified staff are hired to administer medications to the residents. On 2/2/2021, 2/3/2021 and 2/7/2021 LPA made phone call attempts in to identify names of the unqualified staff and dates of hire however was unsuccessful in doing so. On 2/11/2021 LPA M. Berry conducted a visit to the facility and interviewed the med-tech on duty. According to the med-tech upon hire the facility she attended a full day of medication technician training, participated in 16 hours of job shadowing and training with a pharmacist. Based on the lack of supporting information and interviews conducted the allegation is Unsubstantiated at this time.

In regard to allegation # 5 Facility not meeting residents needs it was reported that while living at the facility Resident 1 (R1) sustained a UTI as a result of not drinking enough water. Staff members were informed to provide water to R1 frequently. In addition, R1 was required to be given food prior to administration of a medication, however complainant does not believe this requirement was being followed as R1 was hospitalized twice due to low blood sugar levels. On 2/7/2021 LPA conducted interview with complainant to obtain identifying information for R1 and approximate dates of the hospitalization, however, was unsuccessful. Due to a lack of identifying and supporting information the department is unable to conduct further investigation therefore the allegation is Unsubstantiated at this time.

Exit interview conducted, copy of report emailed to jpink@GlenParkSeniorLiving.com

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

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