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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 01/31/2021
Date Signed: 01/31/2021 06:23:33 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2020 and conducted by Evaluator Wendell Smith
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200124103238
FACILITY NAME:GLEN PARK AT VALLEY VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:PINK, JR, TILLMANFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 45DATE:
01/31/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marcela Higuera (Receptionist)TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not notify resident’s authorized representative of resident being transported to the hospital
Staff did not prevent inappropriate behaviors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith finished a complaint investigation for the allegation 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 with Marcela Higuera.

Staff did not notify resident’s authorized representative of resident being transported to the hospital
Regarding this allegation interviews were conducted with facility staff and R1's representative. Information revealed that R1's representative was contacted regarding R1 being transported to the hospital. Based on the information obtained this allegation was deemed Unsubstantiated at this time.

Staff did not prevent inappropriate behaviors
It is alleged that facility did not stop R1's roommate from exhibiting inappropriate behaviors. Interviews were conducted with facility staff and witnesses. Information obtained revealed that the behaviors alleged did not violate anyone's personal rights and was done in the resident's personal room.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2021
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 31-AS-20200124103238
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GLEN PARK AT VALLEY VILLAGE
FACILITY NUMBER: 197603165
VISIT DATE: 01/31/2021
NARRATIVE
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Based on information obtained from interviews this allegation is deemed Unsubstantiated at this time. Exit Interview conducted. Copy of report emailed for hard signature.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3