197603165-1-26-2022-29-AS-ECAS-CB352W-20220126183500

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 01/26/2022
Date Signed: 01/26/2022 06:37:03 PM

Document Has Been Signed on 01/26/2022 06:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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:	01/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Tillman Pink, Executive Director & Janyce Pink, Assisitant Administrator		TIME COMPLETED:	06:45 PM

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	Licensing Program Analysts (LPAs) Elsie Campos and Salia Walker arrived at the facility unannounced to conduct a required annual visit at 9:25 a.m. This annual had a specific emphasis on infection control practices and procedures. Upon arrival, the LPAs observed one (1) sign posted on the from entrance door noting “Due to increase in COVID cases and for protection of our residents there will be no visitation allowed. Facility is closed to any outside personnel, please give us a call if you would like to speak to a resident and/or employee (818)769-6626. Thank you for your understanding. -Glen Park in Valley Village.” At 9:26 a.m., the LPAs observed two (2) additional signs posted on the right front entrance window noting “ATTENTION ALL VISITORS: AS OF 3/11/2020, IN ORDER TO PREVENT THE INTRODUCTION OF COVID-19 INTO OUR COMMUNITY, WE ARE RESTRICTING ALL NON-ESSENTIAL VISITORS. MORE INFORMATION WILL BE PROVIDED AS WE CONTINUE TO GET UPDATES”; and a reference page with no source provided indicating that there is a Visitation Waiver: “Facility may limit entry to only individuals who need entry as necessary for prevention, containment, and mitigation measures.” There have been various updated CDSS PINS since 3/11/2020. The facility should be implementing the most recent CDSS PIN 22-04-ASC “UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19).” The LPAs advised the Assistant Administrator, and Executive Director that visitation is allowed, as long as the facility follows the visitation requirements per PIN 22-04-ASC. Upon arrival, the LPAs initially met with staff. At 12:00 p.m., Executive Director Tillman Pink, and Assistant Administrator Janyce Pink were observed to have arrived at the facility, and were explained the reason for the visit. The LPAs conducted a physical plant tour with Staff #1 (S1) at 9:35 a.m., to ensure there are no health and safety hazards. Continue on LIC 809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/26/2022

NARRATIVE

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Kitchen: The facility kitchen area appeared clean and sanitary. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food in the refrigerator/freezer were properly labeled. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. The LPAs were unable to measure the Hot water temperature due to the facility heater being in need of repairs.
Bedrooms: The LPAs observed resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
Restrooms: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPAs observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. The resident bathrooms and shower rooms are properly equipped with grab bars and non-skid material. At 9:40 a.m., the LPAs attempted to measure the hot water temperature in the facility common restrooms. The LPAs were then advised that the facility heater was “down” since yesterday 1/25/2022. The LPAs inquired what measures the facility has taken for repairs. S1 advised that staff reported the needed repairs to management. Assistant Administrator Janyce Pink and Executive Director Tillman Pink stated that the facility water heater broke down on 01/25/22, and repairs were made the same day. According to Mr. and Mrs. Pink, the facility water heater broke down again today, and the individuals working on the heater were at the facility today.
The LPAs were unable to measure the Hot water temperature due to the facility heater being in need of repairs.
Common Areas: Fire extinguishers were observed throughout the facility and were fully charged with a service date of 08/25/21. The building is a two-level facility, which consists of offices, activity rooms, medication room, laundry room, multiple supply closets, beauty parlor, staff room, kitchen/dining room, and multiple shower rooms. The LPAs observed common areas, including furniture and activity equipment, to be clean and in good condition. A separate Food Storage room contains additional nonperishable, and perishable food items.
Surrounding Grounds: Entry/exits were free of obstruction. Medication room: First aid kit, medications, and medication records are kept in the medication room. The First Aid Kit was complete with a thermometer, scissor, tweezers, bandage and a first aid manual.
BACKYARD: The patio has covered outdoor areas equipped with furniture for resident use. There were no bodies of water noted.

Continued on LIC 809-C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/26/2022

NARRATIVE

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INFECTION CONTROL: During today’s visit, the LPAs spoke with the Assistant Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPAs did not observe an adequate supply of Personal Protection Equipment (PPE). The executive director and assistant administrator were advised that the facility is able to obtain additional supplies from CCLD as needed as the RO has continued to support licensed facilities through the pandemic without interruption. During the physical plant tour, the LPAs observed that the facility does not have a sufficient 30-Day supply of PPE gear for staff and resident use. Between 12:03 p.m. and 12:15 p.m., it was confirmed based on LPAs observations that the facility does not have sufficient supplies of PPE gear based on LPAs observation of the physical plant. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. During the visit today, S1 informed us that the facility currently has two (2) COVID-19 Positive cases. The LPAs inquired with Staff #2 (S2) if the facility has not reported the COVID-19 Positive Cases to CCLD. S2 confirmed that the COVID cases were not reported to CCLD within 24 hours. At 10:05 a.m., the LPAs were advised by S1 that the facility has had five (5) to six (6) COVID-19 Positive cases in the past month that were unreported. For that reason, the facility management has prohibited all visitors to the residents as of approximately three (3) weeks ago. The LPAs advised the assistant administrator, and executive director that the facility is to report all COVID Positive cases to CCLD per Title 22 Reporting Requirements which threaten the welfare, safety or health of residents within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. The assistant administrator and executive director stated that the facility faxed the incident reports pertaining two (2) residents being positive for COVID-19 to the Woodland Hills North Regional Office (818)596-4376. The LPAs requested to see the fax sheet reflecting the incident reports were successfully faxed to the RO by the facility. The LPAs explained to Mr. and Mrs. Pink that our Department does not have records of incident reports submitted noting Positive COVID cases for January 2022. The Executive Director Tillman Pink stated that "no where in Title 22, does it state that we have to provide you the proof of fax sheet." The LPAs advised Mr. and Mrs. Pink of facility’s policies and procedures as it pertains to infection control which was agreed upon in the facility's Mitigation Plan.

Continue on LIC 809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/26/2022 06:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type B

Section Cited

CCR

87468(a)

87468(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations.. and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above, as the facility does not currently have a sufficient 30-Day supply of PPE gear, which poses a potential personal rights risk to persons in care.
	POC Due Date: 02/02/2022
	Plan of Correction
1 2 3 4	The Licensee has agreed to do the following: 1.The facility will review their Mitigation Plan submitted to CCLD, and implement all practices adhering to directives given by the Department and the California Department of Public Health as it relates to visitation during COVID-19.

Request Denied

Type B

Section Cited

CCR

87211(a)(2)

87211(a)(2) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks.. which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews, the licensee did not comply with the section cited above, as the facility failed to report between five (5) to six (6) COVID cases within 24 hours to the licensing agency, which poses a potential health and safety risk to residents in care.
	POC Due Date: 02/02/2022
	Plan of Correction
1 2 3 4	The Licensee has agreed to do the following: 1.Submit an incident report pertaining to each COVID case the facility has had for the past month. 2.Submit a statement of understating and reviewal of section 87211(a)(2).

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/26/2022 06:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87355(e)(2)

87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, as S3 and S4 have not been associated to the facility, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 01/27/2022
	Plan of Correction
1 2 3 4	The Licensee has agreed to do the following: 1. Ensure that S1 and S2 are associated to the facility prior to allowing S1 and S2 to return to work. S1 and S2 will not work at the facility until proof of association is obtained.

Deficiency Dismissed

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation and interviews, the licensee failed to ensure hot water temperature measured within 105 to 120 degrees Fahrenheit to residents in care due to the facility’s water heater being in need of repairs, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/28/2022
	Plan of Correction
1 2 3 4	The Licensee has agreed to do the following: 1. Submit proof of repairs to the facility's water heater. 2. Submit a five (5) day log on hot water temperature.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/26/2022 06:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type B

Section Cited

CCR

87468.1(a)(11)

87468.1(a)(11) Personal Rights of Residents in All Facilities: (a) Residents in..facilities for the elderly shall have..personal rights:(11)To have their visitors..permitted to visit privately.. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and LPAs observation, the Licensee did not comply with the section cited above, as the facility failed to ensure that residents in residential care where allowed to have their visitors with restrictions in accordance with PIN 22-040-ASC, which poses a potential health and safety risk to residents in care.
	POC Due Date: 01/31/2022
	Plan of Correction
1 2 3 4	No visitation signs were removed during today’s visit. The Licensee has agreed to do the following: 1. All staff will review PIN 22-04-ASC issued on 01/18/2022, and submit staff log to CCLD. 2.Facilty will continue to allow visitation following the updated CDSS PIN, and apply updated changes.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/31/2022
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/26/2022

NARRATIVE

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During the physical plant tour, the LPAs took note of the staff that were working at the time of the visit. During the visit, the LPAs encountered two (2) individuals who identified themselves as staff. The LPAs conducted a record review and confirmed that staff #3 (S3) and staff #4 (S4) are not associated to the facility nor were they indicated on the staff schedule. During the visit Executive Director Tillman Pink stated that S3 is not a staff at the facility, and has no knowledge of the alleged staff that claimed to be the facility's maintenance worker. Tillman Pink confirmed the facility's current maintenance worker is on leave. Executive Director Tillman Pink and Assistant Administrator Janyce Pink denied claim that S3 works at the facility. However, facility staff confirmed that S3 works for the facility, and completes maintenance assignments throughout the facility as needed. Staff also confirmed that S3 has worked in the facility for several months.
The Licensee was previously cited for non-association of staff under section 87355(e)(2) on 12/21/21. Therefore, the facility is being cited for a repeat violation due to S3 and S4 not being associated to facility. Civil Penalties assessed.

While discussing the findings from today's visit, Executive Director Tillman Pink stated to the LPAs he will be refusing to sign the report, and will be appealing the deficiencies; as well as making a formal complain against the LPAs. During the visit, LPAs Walker and Campos returned to the facility once more to deliver the findings to the assistant administrator and executive director. Staff advised the LPAs Mr. and Mrs. Pink departed from the facility, they are not authorized to sign the report, and that the facility does not have a Designee to sign today's report. Staff also stated that the only people authorized to sign the report were the assistant administrator and executive director, Mr. and Mrs. Pink. The LPAs attempted to contact assistant administrator Janyce Pink via telephone twice.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations Title 22. Civil Penalties assessed. Failure to correct deficiencies may result in additional Civil Penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

LIC809 (FAS) - (06/04)

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