197603165-9-7-2022-29-AS-ECAS-CJ2TZ6-20220907150950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 09/07/2022
Date Signed: 09/07/2022 03:10:38 PM

Document Has Been Signed on 09/07/2022 03:10 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 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: 44	DATE:	09/07/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Assistant Administrator-Janyce Pink		TIME COMPLETED:	03:20 PM

NARRATIVE

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Licensing Program Analyst (LPA) Elsie Campos arrived for an unannounced Case Management visit to the facility today in response to an incident that occurred on 9/3/2022. The LPA met with Assistant Administrator Janyce Pink and explained the reason for the visit.

During today's visit, the LPA conducted an interview with the Assistant Administrator and reviewed the staff schedule.

It was reported that Staff #1 (S1) allegedly left the facility during the very early morning of 9/3/2022, (at approximately 1:00 a.m.) leaving the facility residents unattended with no other staff present for approximately 90 minutes. The information received reported that S1 was the only night shift (NOC) staff who had arrived for duty. S1 attempted to contact the licensee representative before leaving the facility; however, the administrator did not respond to the call and S1 needed to leave the facility as they had a family emergency. S1, not knowing what to do, then contacted the Long-Term Care Ombudsman (LTCO) prior to their departure to notify them of the situation. The LTCO contacted Law Enforcement who arrived at the facility to find that there were no staff present in the facility. Law enforcement was able to eventually reach the owner, who then arrived at the facility, along with the assistant administrator, at approximately 2:30 a.m. and arranged for other staff to cover the shift. The Department/Program Administrator received information that the facility was without staff and also spoke with the President/Owner, Tillman Pink Jr., after his arrival to the facility.

Continued on LIC809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

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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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
	VISIT DATE: 09/07/2022

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Regional Manager (RM), Jill Nakata and Licensing Program Manager (LPM) Jeralyn Pfannenstiel called the facility and conducted an interview with the medication staff, Staff #2 (S2) on the morning of 9/3/2022, to confirm there was sufficient staffing at the facility at that time; and, if there were sufficient projected staff for the upcoming NOC shift and the following days. Thereafter, at 9:45 a.m., the RM and LPM spoke with Janyce Pink, assistant administrator. The assistant administrator stated that they were not made aware of the staffing issue until the police notified the owner and made them aware. It was stated that staff are supposed to give a four-hour notice if they are going to call off for their shift so that the facility can find sufficient coverage; however, this did not occur in this instance. Two of the regular NOC shift staff were off due to illness and they were allegedly replaced with two Home Care Staff who failed to report for duty. As a result, there was only S1 on duty. In addition, the assistant administrator stated that S1 was new, but they should have tried to reach them by phone more than just once. The assistant administrator was able to confirm that they would have sufficient staffing over the long holiday weekend. She stated that if there is an instance when the NOC shift staff will be unavailable, the PM staff are often able to stay a little longer until a replacement staff can be found for the NOC shift.

Based on the information received, it was confirmed that the facility lacked staff presence in the facility and on-duty supervision from approximately 1:00 a.m. to 2:30 a.m., which is a violation of Title 22 Regulations.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, today's report and appeal rights were reviewed and issued. An immediate Civil penalty was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/07/2022 03:10 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: 09/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 09/12/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. Submit an updated staffing schedule. Submit a Statement of Understanding, demonstrating how the facility will maintain adequate staffing to meet the needs of the residents
	8 9 10 11 12 13 14	Based on information received, the licensee did not comply with the section cited above, as the facility experienced an incident where there were no staff present in the facility for approximately one-hour, if not longer, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	and conduct emergency protocol training pertaining to staffing and call offs. Submit proof to CCL by 9/12/2022. An Immediate $500 Civil Penalty was issued during today’s visit.
	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: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC809 (FAS) - (06/04)

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