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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 02/14/2023
Date Signed: 02/14/2023 04:29:49 PM

Substantiated


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
10/28/2020 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20201028140553
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: 57DATE:
02/14/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jessyca MunozTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident fell and was left on the floor until the following morning.

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 representative at 11:30 a.m., and explained the reason for the visit. Staff stated that the administrators were not available, and staff would notify them of the visit.
On 11/03/2020, Licensing Program Analyst (LPA) Brian Basili 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, the complaint investigation was conducted telephonically at 03:50pm with Elizabeth Flores, the facility Assistant Administrator. Between3:50pm - 4:30pm LPA Basili conducted telephone interviews with the administrator, and a video call which consisted of a review of physical plant. The 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 on today’s date. Further investigation is required at this time.
Continues on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 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)
Page: 1 of 5
Control Number 29-AS-20201028140553
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 fell, and was left on the floor until the following morning’; it is the complainant’s concern that R1 had fallen during the night, and was not found until the med tech passed the next morning. On 02/07/2023, LPA Urena conducted record review of documents submitted to LPA Basili during the initial investigation by the complainant and the facility. The record review submitted by the complainant revealed that the facility verified via an Incident Report that R1 had indeed fallen on 09/10/2020 and was found on the floor on 09/11/2020 by a facility staff. LPA Urena conducted six (6) resident interviews pertaining to the allegation, and five out of six the interviews revealed that although the rooms have a call system, it may take staff at least 30 minutes to respond to the call/light. Additionally, the residents’ interviews revealed that the facility often experiences staff shortage, and although caregivers are very nice, they may not always respond in a timely manner. The record review of R1’s file revealed that the pre-placement appraisal dated 05/22/2020 states that R1 is non-ambulatory due to R1’s use of a walker, and that R1 requires assistance when using the toilet.

Based on the information obtained through record review, and interviews; there is sufficient evidence to support the allegation that the resident fell, and was left on the floor until the following morning. Therefore, this allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-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.



Citations were issued. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 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)
Page: 2 of 5
Control Number 29-AS-20201028140553
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: (4)To care, supervision, and services that meet their individual needs...and are delivered by staff that are sufficient in numbers,.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following: 1. Submit a Plan of Action, detailing how staff are trained to respond to resident falls (witnessed and unwitnessed). In addition, detail the facility's protocol surrounding fall prevention. Submit to CCL by 2/24/2023
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Based on the investigation, licensee did not comply with the section cited above, as staff did not provide adequate supervision, resulting in a resident falling, which poses an immediate health and safety risk to residents 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: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/28/2020 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20201028140553

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: 57DATE:
02/14/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jessyca MunozTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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2
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Facility staff does not provide basic needs to residents.
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 representative at 11:30 a.m., and explained the reason for the visit. Staff stated that the administrators were not available, and staff would notify them of the visit.
On 11/03/2020, Licensing Program Analyst (LPA) Brian Basili 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, the complaint investigation was conducted telephonically at 03:50pm with Elizabeth Flores, the facility Assistant Administrator. Between3:50pm - 4:30pm LPA Basili conducted telephone interviews with the administrator, and a video call which consisted of a review of physical plant. The 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 on today’s date. Further investigation is required at this time.
Continues on LIC 9099A-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 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)
Page: 4 of 5
Control Number 29-AS-20201028140553
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 ‘Facility staff does not provide basic needs to residents’; it is the concern of the complainant that the facility does not provide supports for individuals based on their need. Someone to take care of the basic needs of the residents - such as attending medical appointments outside the facility. To investigate the allegation, LPA Urena conducted staff and residents’ interviews from 12:30 to 2:15 p.m., and record review pertinent to the allegation at 1:15 p.m. The LPA interviewed seven residents, and four out of seven stated that they typically go to the front desk to let them know of an upcoming appointment, and the staff will book the van for them for the date and time of the appointment. Two out of the seven residents stated that the staff will book their appointments for them. Two out of the seven residents stated that they will use other means of transportation such as Access, or public transportation. Residents stated that the facility staff who takes them to the appointments usually waits for them, but there are times when the staff, will come back to pick them up once the appointment is over. The LPA requested copies of the Chauffer Service Sign-Up sheet, and the LPA was able to verify through interviews that the residents on the sign up lists were taken to their appointments. The staff’s interview revealed that residents typically let the front desk person of their upcoming appointments and sign up for the van transportation service.

Based on the information obtained through record review, and interviews; there is insufficient evidence to support the allegation that the facility does not provide supports for individuals based on their need. Therefore, this allegation is deemed Unsubstantiated at this time.

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

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 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)
Page: 5 of 5