197603165-12-21-2021-29-AS-JAPL-CDUTJB-20220426144604

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 12/21/2021
Date Signed: 12/21/2021 04:50:36 PM

Unsubstantiated

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
12/08/2021 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20211208140455

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: 34	DATE:	12/21/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Elizabeth Flores		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Facility did not ensure resident signed an Admission Agreement

Staff are not providing a comfortable environment for resident

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Elsie Campos and Ashley Smith arrived unannounced for a subsequent complaint visit. The LPAs met with Office Manager Elizabeth Flores and explained the reason for the visit.

During the initial visit on 12/16/2021, the LPA’s conducted a brief facility tour at 1:50 p.m., interviewed resident at 2:00 p.m., interviewed staff at 2:18 p.m. and reviewed documents at 1:28 p.m. During today’s visit, the LPAs spoke to staff at 11:40 a.m. and 11:58 a.m.; spoke to residents at 12:21 p.m., 1:21 p.m., 1:23 p.m., 1:29 p.m.; 1:40 p.m. and 1:45 p.m.

Cont. on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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-20211208140455

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: 12/21/2021

NARRATIVE

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Allegation: Facility did not ensure resident signed an Admissions Agreement
Regarding the complaint, it was alleged that Resident 1 (R1) did not sign an Admissions Agreement. During today’s visit the LPA’s interviewed R1 in which R1 admitted they signed an admissions agreement but was not clear of the contents. During the initial visit conducted by the LPA’s on 12/16/21 a copy R1’s signed admissions agreement was obtained. After reviewing the admissions agreement, it was determined that R1 had signed and initialed all required areas of the admissions agreement. Based on the investigation, this allegation is deemed unsubstantiated at this time.

Allegation: Staff are not providing a comfortable environment for resident
Regarding the complaint, it was alleged that staff were not providing a comfortable environment for Resident 1 (R1) because they were being issued invoices. Additionally, R1 was feeling uncomfortable due to their inability to pay. An interview with R1 revealed that R1 felt that staff were doing their jobs and acted in a professional manner when issuing the invoices and requesting payment. R1 denied claims that staff were being rude, disrespectful, or demeaning. Interviews with randomly selected residents revealed that staff are respectful and act professionally. Based on the investigation, this allegation is deemed unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC9099 (FAS) - (06/04)

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