197603165-11-1-2022-29-AS-JAPL-CKY236-20221107160146

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 11/01/2022
Date Signed: 11/01/2022 03:19:08 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
06/02/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-NP-20220602144709

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:	ZIP CODE:	91607
CAPACITY:	100	CENSUS: 48	DATE:	11/01/2022
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Jessyca Munoz		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Licensee failed to create a safe enviornment for residents
Licensee failed to meet resident hygiene needs
Licensee failed to treat resident with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for a subsequent complaint visit. The LPA met with Receptionist Jessyca Munoz and explained the reason for the visit. Administrator was not available at the time of the visit and report was delivered to designated staff Jessyca Munoz.

On 6/7/2022 LPA's Elsie Campos and Ashley Smith conducted a file audit from 1:50 p.m. - 2:10 p.m., conducted a physical plant tour at 1:40 p.m., interviewed residents at 2:20 p.m., 2:55 p.m., 3:01 p.m., 3:02 p.m., 3:05 p.m., 3:07 p.m., and 3:10 p.m.; and, interviewed staff at 2:42 p.m. and 3:18 p.m. On today’s date, the LPA returned to the facility to resolve the complaint allegations and interviewed resident at 1:40 p.m.

Continued on LIC 9009-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: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

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-NP-20220602144709

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: 11/01/2022

NARRATIVE

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Licensee failed to create a safe environment for residents: It is alleged that Resident #1 (R1) feels unsafe at the facility. Interview with R1 revealed that they did not feel comfortable at the facility but was unable to provide any details why that was the case. Interviews with Resident #2 and Resident #3 (R2, R3) did not reveal any concerns regarding safety at the facility. Staff indicated R1 has good and bad days that include R1 crying, screaming, and had indicated that R1 was unhappy when they were admitted here stating that they missed their family. Overtime R1 adjusted, but still made remarks to staff that they didn’t like it here. R1 revealed that they would be moving to a new facility but did not indicate when. When R1 is having a good day, staff are able to provide all of the services without any issues from R1. Based on interviews, there is insufficient evidence to determine whether this allegation may or may not have happened, this allegation is deemed Unsubstantiated at this time.

Licensee failed to meet resident hygiene needs: It is alleged that staff are not helping Resident #1 (R1) with showers or being assisted with brief changes. R1 confirmed that they are helped with showers twice a week and assisted with toileting whenever it is needed. Interviews with Resident #2 and Resident #3 (R2, R3) did not reveal any concerns regarding hygiene needs being unmet and indicated that that they are helped when they request it. Staff indicated R1 has good and bad days that include R1 crying, screaming declining services such as showers and will pick and choose which caregivers to comply with. Staff indicated that they provide two showers a week to R1. When R1 is having a good day, staff are able to provide all of the services without any issues from R1. Based on interviews, there is insufficient evidence to determine whether this allegation may or may not have happened, this allegation is deemed Unsubstantiated at this time.

Licensee failed to treat resident with dignity and respect: It is alleged that staff yell at Resident #1 (R1). R1 revealed that staff are okay but did not provide any details regarding staff yelling. R1 indicated that they cry sometimes because they miss their family. Interviews with Resident #2 and Resident #3 (R2, R3) did not reveal any concerns regarding staff yelling or staff treating them without dignity and respect. R2 and R3 indicated that they are treated good by staff and have no concerns. Staff indicated R1 has good and bad days that include R1 crying, screaming declining services. Staff interviews revealed that R1 has previously expressed to them that they are not treated good by staff due to their dissatisfaction with staff being unable to stay with them 24/7. Staff additionally denied claims that staff are rude or disrespectful to residents in care. Based on interviews there is insufficient evidence to determine whether this allegation may or may not have happened, this allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. Report signed and delivered.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

LIC9099 (FAS) - (06/04)

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