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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 04/12/2022
Date Signed: 04/12/2022 07:59:38 PM


Document Has Been Signed on 04/12/2022 07:59 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 VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:PINK TILLMANFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 35DATE:
04/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Roxanna RodasTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20210930102747.

On 10/06/2021, at 10:20 a.m. while LPA Urena, and Assistant Administrator conducted a tour of the facility, the LPA observed holes in the walls, and ceilings with some wiring exposed. Assistant Administrator stated that the call system wiring was being updated. LPA observed holes in the hallways’ walls and ceilings, as well in residents’ rooms and observed holes in the walls and ceilings right above the headboard and next to the bed. The holes remained open for approximately a period of three months, and the facility did not put up any type of plastic barrier to prevent debris from dropping from the holes while in the process of waiting for the repairs.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).



Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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Document Has Been Signed on 04/12/2022 07:59 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: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
04/12/2022
Section Cited

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87303-Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times.



This requirement is not met as evidence by:
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Based on observation, and interviews: During the physical plant inspection, LPA Urena observed holes in the hallways’ walls and ceilings, as well in residents’ rooms 23 and 20, with some wiring exposed. which poses a potential Health, Safety, and Personal rights risk for persons in care.
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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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
LIC809 (FAS) - (06/04)
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