197603165-1-4-2023-29-AS-ASMH-CMRS96-20230104124014

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 01/04/2023
Date Signed: 01/04/2023 12:41:12 PM

Document Has Been Signed on 01/04/2023 12:41 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:	TILLMAN PINK		FACILITY TYPE:	740
ADDRESS:	5527 LAUREL CANYON BLVD		TELEPHONE:	(818) 769-6626
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	100	CENSUS: 54	DATE:	01/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Assistant Administrator Janyce Pink		TIME COMPLETED:	01:00 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) Ashley Smith and Sandra Urena arrived unannounced to conduct a required annual inspection. The LPAs met with Assistant Administrator Janyce Pink and explained the reason for the visit.

The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: LPA Smith observed the kitchen area at 10:35 a.m. The facility has a sufficient supply of non-perishable and perishable food items. Appliances appeared to be in operable condition. The menu was posted. The kitchen and dining room area was observed to be clean and in good condition.

Resident Rooms: Between 10:20 a.m. – 10:40 a.m., LPA Urena observed five (5) resident rooms. Rooms appeared to be well kempt and in good condition. During the room inspection, LPA Urena tested the water temperature. Water temperature ranged between 108.8 degrees F – 122.0 degrees F. Out of the five (5) bathrooms tested, the water temperature in the restroom of Room #41 registered at 122.0 F at 10:36 a.m., and the water temperature in the restroom of Room #46 measured at 120.3 F at 10:39 a.m.

Common areas: The facility is a two-story building with resident rooms on both floors. Staff were observed wearing appropriate face coverings throughout the visit. In addition, the LPAs observed hands-free hand sanitizer interspersed throughout the common grounds.

There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature at 72 degrees. There are fire extinguishers throughout the facility, which were charged and last serviced 9/2022. The activity schedule was posted throughout the facility. The activity rooms and common spaces appeared clean and in good repair.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: 01/04/2023

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
26
27
28
29
30
31
32

There are laundry rooms on the first and second floor. At 10:25 a.m., LPA Smith observed that the laundry room on the second floor was unlocked. Upon entry, the flooring was observed to be unclean. In addition, there was accessible cleaning supplies in the laundry room. At 10:28 a.m., the LPA observed that the laundry room on the first floor was unlocked. As such, there was accessible bleach and laundry detergent found in the unlocked laundry room. During today’s visit, the Administrator spoke with staff regarding this discrepancy and staff communicated their commitment to continued compliance in the future. Items were locked inaccessible during today's visit.

Outside areas: There is a small courtyard with appropriate outdoor furniture for resident use, and a larger outdoor area adjacent to the kitchen, which had additional covered seating for resident use. There were no bodies of water noted.

Infection Control: There was a central entry point for residents and guests to sign in and temperature checks. Staff were wearing appropriate face coverings. Infection Control signs were observed throughout the facility. Facility had a sufficient supply of Personal Protection Equipment (PPE); however additional supplies were requested. The facility’s cleaning protocol was sufficient. The facility keeps record of staff and resident vaccinations. Staff are up to date regarding visitation protocol and vaccine requirements. The facility continues to conduct weekly surveillance testing of staff and residents. The facility's procedures as it pertains to infection control were adequate.

Other: During today's visit, the Assistant Administrator discussed the licensee's intent to install additional delayed egress doors. The LPAs encouraged them to inform CCL as to their timeline, as this will require additional documentation and inspection. The LPAs also discussed the use of wireless alarms on all exit doors, in which the Assistant Administrator noted that they would look into this further.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in 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: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/04/2023 12:41 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: 01/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

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 observation, the licensee did not comply with the section cited above in two (2) out of five (5) restrooms where the hot water temperature measured above 120 degree F, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/04/2023
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Staff will adjust the water tank by the end of the day. 2. Keep a water temperature for four (4) rooms (two upstairs, two downstairs) for three days. Submit the water temperature log no later than 1/11/2023.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as the laundry rooms on the 1st and 2nd floor were unlocked and there were cleaning supplies and laundry detergent accessible to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/04/2023
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Items were locked during today's visit. Plan of Correction met at this time.

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: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/04/2023 12:41 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: 01/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(1)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as the laundry room flooring on the 2nd floor was unclean, which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/09/2023
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Clean the flooring on the second floor of the laundry room. Submit photographc proof of completion by 1/9/2023

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	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: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4