197603165-11-1-2022-29-AS-JAPL-CLFVMV-20221123153412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 11/01/2022
Date Signed: 11/01/2022 03:16:41 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
10/28/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20221028135145

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:	ZIP CODE:	91607
CAPACITY:	100	CENSUS: 48	DATE:	11/01/2022
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Jessyca Munoz		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility did not report incidents to CCL or Regional Center

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for an initial complaint visit. The LPA met with Receptionist Jessyca Munoz and explained the reason for the visit. Administrator was not available at the time of the visit and report was delivered to designated staff Jessyca Munoz. During today’s visit, the LPA conducted a file audit at 10:00 a.m. and collected pertinent documents.

Regarding the allegation: Facility did not report incidents to Community Care Licensing (CCL) or Regional Center
It was alleged that the licensee failed to submit incident reports pertaining to Resident #1 (R1). A review of internal records revealed that the licensee has records of CCL incident reports drafted regarding incidents for R1 on 4/4/22 and 4/14/2022 and has Regional Center reports drafted for incidents on 2/9/2022, 4/4/2022 4/14/2022 and 5/3/2022 however the licensee did not submit the drafted incident reports to CCL or Regional Center as verified per CCL's electronic filing system.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

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-20221028135145

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: 11/01/2022

NARRATIVE

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The licensee failed to ensure that incidents were reported regarding R1 to CCL and Regional Center that occurred on following dates: 9/26/2022 - ER visit due to chest pain, 9/15/2022 treatment for scabies and quarantine, 8/15/2022 - ER visit due to swollen ankle. 7/12/2022 - COVID results, 5/12/2022 to 5/16/2022 - Hospitalization, 5/2/2022, Peanut allergy transported to hospital, 4/14/2022 Fall, 4/4/2022 arm injury transported to hospital, 2/9/22 - ER visit due to chest pain & swollen ankle.

Based on the information obtained, there is sufficient evidence to support the claim that the licensee failed to comply with reporting requirements. 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.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221028135145

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: 11/01/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 11/11/2022 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. Submit incident reports for R1’s incidents and/or hospitalizations for the record. Review the report for exact dates. Submit to CCL no later than 11/11/2022. 2. Conduct staff training on incident reporting and submit proof to CCL by 11/11/2022.
	8 9 10 11 12 13 14	Based on record review, the licensee did not comply with the section cited above, as reports were not submitted for all of R1’s incidents to both CCL and Regional Center, 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: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

LIC9099 (FAS) - (06/04)

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