197603165-3-24-2022-29-AS-DPEA-CD28AP-20220330222100

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 03/24/2022
Date Signed: 03/24/2022 04:08:00 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
05/27/2020 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20200527112806

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: 37	DATE:	03/24/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Janyce Pink - Assistant Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not follow up with resident's doctor appointment

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to investigate the above allegation. LPA met with Administrator Till Pink and Assistant Administrator Janyce Pink and explained the reason for the visit.
During the course of the investigation LPA initiated the investigation virtually on 6/3/2020 and conducted physical plant tour virtually and obtained copies of documents pertinent to the investigation. A subsequent visit was also conducted on 12/29/2021, which LPA conducted physical plant tour, interviewed staff and residents as well as reviewed and obtained copies of documents pertinent to the investigation. Today LPA reviewed additional pertinent documents along with Assistant Administrator.

Regarding allegation that facility did not follow up with Resident 1 (R1)'s doctor appointment, LPA records review of resident file including hospital discharge records, appointment confirmations, and after visit summaries revealed that R1 appeared to have attended each medical appointment scheduled from November 2019 up until when R1 relocated from this facility at this time.

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: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

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 3

Control Number 29-AS-20200527112806

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: 03/24/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 9099

In addition, further records review revealed that R1 was visited by physicians at the facility beginning November 2019 up until time R1 relocated from this facility. LPA review of facility appointment calendar revealed that residents in care appear to be attending their appointments in a timely manner for the time period reviewed at this time. LPA interview with (10) residents revealed that most do no recall ever missing a medical appointment , but in the past, if they were ever to miss an appointment most remembered appointments would be rescheduled in a timely manner. Based on information obtained during today's and previous visits, the department does not have enough evidence to support the allegation listed above. Therefore the allegation that Facility did not follow up with R1's doctor appointment has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted. 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: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3