<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 05/24/2023
Date Signed: 05/24/2023 12:01:25 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
05/22/2023 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20230522091531
FACILITY NAME:GLEN PARK AT VALLEY VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:TILLMAN PINKFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 54DATE:
05/24/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rafael SilvaTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has bed bugs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Angel Ascencio conducted an initial 10-day complaint visit to the above facility. LPA met with Interim Administrator Rafael Silva and Quality Assurance Specialist (QA) Elizabeth Monarrez at 09:30 a.m. Entrance interview conducted.

On 05/22/2023, the Department received a complaint regarding the facility not taking appropriate measures to eradicate bed bugs. On 05/24/2023, starting at 09:30 a.m., interview with QA Monarrez revealed that Resident #1 (R1) has bed bugs. R1 moved in the facility about 6 month ago and has been refusing care and housekeeping services. QA Monarrez stated although the R1 does have a right to refuse care and housekeeping services, it has come to the point that is very unhealthy and poses a danger to R1 and other around due to self-neglect. Additionally, R1 was moved to another room in order to deep clean the room R1 was living at, but continued to refuse showers.

Continued on LIC 9099 – C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
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 3
Control Number 29-AS-20230522091531
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: 05/24/2023
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
That same day, interviews with various staff members, starting at 09:52 a.m., confirmed R1 having bed bugs and confirmed R1’s refusal for all activities of daily living (ADL).

Additionally, staff stated R1 expresses aggressive behaviors at anyone, fearing that R1 would be combative towards staff or other residents. Lastly, R1 has been on isolation protocol for bed bugs since discovering them on May 16th. That same day, interview with R1, starting at 10:40 a.m., revealed that R1 has been refusing care due to a rent increase. R1 added they feel targeted because of the increase, but once that gets resolved, they will cooperate and have staff help them with showers and have housekeeping clean their room. During R1 interview, LPA Ascencio observed R1’s bed sheet, coffee table and floor covered in tiny, black pest. Interview with Interim Administrator Silva revealed that R1 moved into the facility about 6 months ago and has not had an increase in rent. Administrator Silva added that they moved R1 to a different room to clean the previous room they lived in. LPA Ascencio observed R1’s previous room and did not observe any pest in the room. Administrator Silva added that they will continue to spray the room and possibly have an entire cleaning of all rooms for any pest. Lastly, Administrator Silva added that R1 is a Regional Center client, which they pay for R1 board and care completely. LPA Ascencio advised Administrator Silva to continue to reach out to R1’ primary physician and to contact Los Angeles Public Health (LAPH) for guidance on bed bugs.

Based on the information obtained there is sufficient evidence to support the allegation of facility has bed bugs. Therefore, the allegation is deemed Substantiated at this time.



Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20230522091531
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: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2023
Section Cited
CCR
87468.1
1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will have a pest control company assess all resident room for pest control. Additionally, Administrator will come up with a plan to keep the facility free of pest and a plan to offer R1 additional help.
8
9
10
11
12
13
14
Based on interviews and observation, the facility did not provide R1 a safe, healthful and comfortable accommodations, as bed bugs were observed and interviews confirmed bed bugs which poses a potential health, safety, and personal rights risk to 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3