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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 07/06/2023
Date Signed: 07/06/2023 01:17:45 PM


Document Has Been Signed on 07/06/2023 01:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:TILLMAN PINKFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 49DATE:
07/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Rafael SilvaTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management - Deficiency visit to the above facility. LPA Ascencio met with Quality Assurance Specialist (QA) Elizabeth Monarrez at 10:45 a.m. Interim Administrator Rafael Silva arrived shortly after.

During today's visit, a medication audit was conducted starting at 11:25 a.m. LPA Ascencio observed the Centrally Stored Medication Record for Resident #1 (R1) and did not observe Olanzapine 10 mg, Clozapine 50 mg, and Clorazapine 100 mg centrally stored. Staff #1 (1) stated R1 was switched over to a new medication the previous week and was not included on the routine medication list. Because of this change, the pharmacy sent R1 medication "off-cycle", and was not included on the centrally stored medication. S1 added that they will add the three (3) medications to the centrally stored.

1 citation was observed during today’s visit.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited
(refer to LIC 809-D).

A copy of this report and appeal rights were provided to Administrator Silva.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2023 01:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2023
Section Cited
CCR
87465(a)(6)

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87465 Incidental Medical and Dental Care (a)(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
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Administrator will conduct a medication audit for all resident medication which should be accurate and centrally stored. Admininstrator will come up with a plan to check medication is accurate and centrally stored.
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Based on evidence gathered through a medication audit, the licensee did not comply with the section cited above as R1 did not have their medication centrally stored which poses a potential health, safety and personal rights risk to person 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
LIC809 (FAS) - (06/04)
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