197603165-7-1-2021-29-AS-DPEA-C56P9Q-20210722110732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 07/01/2021
Date Signed: 07/01/2021 02:02:36 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
03/19/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210319152945

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: 36	DATE:	07/01/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Pink Tillman - Assistant Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the above allegation. LPA met with Assistant Administrator

During the course of the investigation, LPA conducted a physical plant tour virtually on 03/25/2021 as well as interviewed Administrator. On 6/4/21 LPA conducted interviews with facility staff and other relevant parties.
LPA also gathered and reviewed facility documentation pertinent to the allegation.

Regarding the allegation of illegal eviction, LPA records review and interview with Resident 1 (R1) revealed that R1 never received an eviction notice and was never evicted. R1 stated there was an incident involving police and R1 had to be taken to the hospital. R1 also stated they are at a different faciltiy at this time.

Continued on 9099-C

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: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

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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Control Number 29-AS-20210319152945

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: 07/01/2021

NARRATIVE

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continued from 9099

LPA interview with the Assistant Administrator Flores further revealed that R1 was never given a written or verbal notice of eviction. Flores also stated that R1 is at a skilled nursing facility at this time due to an incident that involved police, where R1 had to vacate the facility. Based on information gathered during this and previous visit the department does not have sufficient evidence to determine that facility illegally evicted resident. Therefore, the above allegation is UNSUBSTANTIATED at this time.

Exit interview conducted, copy of report issued and sent via Email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

LIC9099 (FAS) - (06/04)

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