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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 11/15/2022
Date Signed: 11/15/2022 04:12:38 PM


Document Has Been Signed on 11/15/2022 04:12 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: 49DATE:
11/15/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Jessyca Munoz and Joysie CallejasTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced Plan of Correction/Case Management (POC) visit to follow up on the Plan of Correction citation issued during the complaint visit conducted on 11/01/2022 complaint # 29-AS-20221028135145. 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 Joysie Callejas as Jessica Munoz left for the day.

During today’s visit, the LPA spoke to front office staff Jessyca Munoz regarding the incident reports requested on the previous complaint visit. Staff was unable to produce the missing incident reports or proof of training as indicated on the plan of correction issued on 11/1/2022. In addition, it was observed that additional incident reports for Resident #1, #2 and #3 (R1, R2, R3) were not submitted to CCL and Regional Center as required for R1's hospitalization on 8/23/2022. The LPA confirmed that R1 was hospitalized, and CCL was not notified as required.

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. Civil penalties assessed
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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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