197603165-3-10-2023-29-AS-JAPL-CQZ3PH-20230417182533

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 03/10/2023
Date Signed: 03/10/2023 05:24:52 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
02/09/2021 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20210209095613

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:	03/10/2023
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Tillman Pink		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Facility did not notify the resident's POA of moving him to the hospital.

INVESTIGATION FINDINGS:

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On 03/10/2023, Licensing Program Analyst(LPA) Sandra Urena, conducted an unannounced subsequent visit to investigate the allegations above, and deliver the findings. The LPA arrived at 10:35 a.m., met wit Administrator Tillman Pink, and explained the reason for the visit.

On 02/11/2021, 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, the complaint investigation was conducted telephonically at 11:00am with Elizabeth Flores, the facility Assistant Administrator. Between 12:30pm - 1pm LPA Basili 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. On 2/12/2021, LPA Basili interviewed the complainant at 11:15am, and interviewed Administrator Elizabeth Flores between 12:30 p.m. to 1:00 p.m.
Continues on LIC 9099C...

Substantiated

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: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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-20210209095613

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: 03/10/2023

NARRATIVE

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On the allegation that the ‘Facility did not notify the resident's POA of moving R1 to the hospital’; it is the complainant’s concern that on 01/22/2021 R1 had food poisoning, and also tested positive for COVID-19, R1 was sent to the hospital, and facility failed to inform the POA about sending R1 to the hospital. To investigate the allegation LPA Urena interviewed the complainant on 03/10/2023 from 11:40 a.m. to 12:16 p.m. The interview revealed that the hospital contacted POA on 01/22/2022 to inform them that R1 had been admitted to the hospital. POA never received a call from the facility to inform them that R1 was taken to the hospital. On 02/11/2021, LPA Basili Interviewed Administrator Elizabeth Flores regarding contact protocols for residents being admitted to the hospital. According to the Administrator, staff are to always notify responsible parties for hospital visits. In regard to resident R1, facility staff were dealing with a COVID outbreak at the time, and R1 was showing shortness of breath so staff called an ambulance for R1. In that process, the Administrator believes they called the R1’s responsible party from the Administrator’s office phone. However, Administrator stated they do not have a record at this time. LPA Urena conducted a file review on 03/10/2023 in the department’s data system/server to try to locate the LIC 624-Incident Report Form that would have informed the department of the hospitalization of R1, and those notified; however, the LPA was unable to locate the LIC 624.

Base on the information obtained through the interviews, there is sufficient evidence to support the allegation that ‘Facility did not notify the resident's POA of moving R1 to the hospital’. 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. The facility's representative sign off the report. A copy of the report and Appeal Rights were issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210209095613

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: 03/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/17/2023 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211(a)(1)(D) Reporting Requirements. A written report shall be submitted … within seven days of the occurrence of any of the events specified ... (D) Any incident which threatens the welfare, safety or health of any resident ... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee has agreed to do the following:1) Inform the CCLD that the Licensee has reviewed the regulation related to reporting requirements and self certify via a letter that they have completed the review, and submit proof via a self-certification letter to CCLD by 03/17/2023.
	8 9 10 11 12 13 14	Based on record review, and interviews, the licensee did not comply with the section cited above, as R1’s POA and CCLD were not informed of R1’s hospitalization, which poses a potential health and safety risk for residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC9099 (FAS) - (06/04)

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