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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 03/29/2022
Date Signed: 03/29/2022 10:58:14 AM



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 VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:PINK, JR, TILLMANFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 37DATE:
03/29/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Qwutaria Rogers - Office Manager TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility did not file incident reports in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to investigate the above allegation. LPA met with Qwutaria Rogers office manager who stated they have authorization from the Administrator to sign and receive reports.

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. On 3/24/2022 LPA reviewed additional pertinent documents along with Assistant Administrator.

Today LPA conducted physical plant and interviewed staff.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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 2
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: 03/29/2022
NARRATIVE
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Continued from 9099

It was alleged that facility did not file incident reports for Resident 1 (R1) in a timely manner. LPA records review of R1's incident log from November 2019 up until when R1 relocated from the facility revealed that incident reports were filed and appeared to be faxed to the appropriate parties as it was documented by fax transmittal letters and fax stamps at this time. LPA records review of incident reports sent out in the last three months were observed to be appropriately filed and documented at this time. 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 file incident reports for R1 in a timely manner has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2