197603165-2-14-2023-29-AS-JAPL-CP42BZ-20230215161557

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 02/14/2023
Date Signed: 02/14/2023 04:26:54 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
11/18/2020 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20201118132347

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: 57	DATE:	02/14/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Jessyca Munoz		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained unexplained bruising while in care.

INVESTIGATION FINDINGS:

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On 02/14/2023, Licensing Program Analyst (LPA), Sandra Urena, conducted an unannounced subsequent visit to further investigate the allegations listed above. LPA Urena met with facility staff at 11:30 a.m., and explained the reason for the visit. Staff stated that the administrators were not available, and staff would notified them of the visit.

Licensing Program Analyst (LPA) Brian Balisi initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically at 03:00pm with Elizabeth Flores, the facility administrator. Between 3pm - 3:30pm LPA conducted telephone interviews with the administrator and a video call which consisted of a review of physical plant. LPA also requested copies of Census, Staff schedule, admission agreement and resident documentation relevant to the investigation, to be emailed to the LPA by end of business day today. Further investigation is required at this time.
Continues on LIC 9099C ...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

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-AS-20201118132347

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: 02/14/2023

NARRATIVE

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On the allegation that the ‘Resident sustained unexplained bruising while in care’; it is the concern of the complainant that R1 sustained an excessive amount of bruising on their thigh. The R1 was complaining of pain, and disclosed the bruises to the complainant. To investigate the allegation, on 02/11/2023, LPA Urena reviewed documentation provided to LPA Baisili. The record review did not provide evidence of the complaint, additionally the record review did not reveal medical records that document the bruises found on R1’s thigh. Furthermore, LPA Urena conducted a facility folder review in the CCLD Server (database), and the folder review did not revealed reports pertaining to the allegation. LPA Urena was not able to reach either R1 or complainant for an interview.

Although this may have happened, there is insufficient evidence to support the allegation that the Resident sustained unexplained bruising while in care. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted with facility representative. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

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