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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 02/07/2023
Date Signed: 05/04/2023 05:12:23 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
02/06/2023 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20230206132519
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: 57DATE:
02/07/2023
UNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Tillman PinkTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility abandoned resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This report was amended on 03/30/2023 to include additional information which does not change the findings.
Licensing Program Analyst (LPA) Angel Ascencio conducted an initial complaint visit to the above facility. LPA met with staff member at 10:13 a.m. LPA Ascencio met with Administrator Tillman Pink at 1:15 p.m. Entrance interview conducted.

On 02/06/2023, the Department received a complaint alleging that facility abandoned resident. On 02/07/2023, starting at 8:10 a.m., LPA Ascencio conducted an interview with Case Worker (CW). Interview with CW revealed that on 02/03/2023, Resident #1 (R1) was admitted to the hospital for a pressure injury on their left foot. R1 was seen by a physician and a Emergency medical technician (EMT) who bandaged R1's injury. One (1) hour had elapsed and was ready for discharged. CW stated the hospital contacted the facility administrator, Tillman Pink, who refused to accept the resident stating the facility is unable to take care of the wounds and needs of R1. Various attempts were made by other hospital workers on 02/05/2023 and 02/06/2023 but all were denied the return of R1. 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: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
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 5
Control Number 29-AS-20230206132519
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: 02/07/2023
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
CW added that they felt that the facility abandoned R1 because of the wound and was unlawful to not accept the resident back. Later that same day, starting at 10:29 a.m., interview with R1 revealed that they moved into the facility on 01/27/2023. Upon admission, R1 added that the facility was aware of the wound on their leg and proceeded with admission. R1 stated that during the signing of intake documents, the Administrator and staff were demanding that R1 to go to the hospital for an evaluation of the leg. R1 added that they have been receiving home health wound services for six (6) months. R1 stated that on 02/03/2023, the paramedics came to take to them to the hospital. R1 stated they felt afraid, lied to and abandoned as the facility sent them out to the hospital and didn't not want to accept them back because of the pressure injury to their leg. That same day, interview with outside agency, starting at 12:41 p.m. confirmed what R1 and CW stated. Outside agency added that on 02/05/2023, the hospital spoke to a staff member who stated that R1 could not return to the facility. Additionally, on 02/06/2023, outside agency was able to speak with Administrator Pink regarding the return on R1 to the facility. R1 returned to the facility on 02/06/2023. That same day, interview with Administrator Tillman Pink, starting at 1:15 p.m revealed that the facility was out of compliance because of a stage 3 pressure injury to R1's leg that needed medical attention. A review of medical documents obtained for R1, which started at 11:45 a.m., revealed that the discharge documentation from the hospital stated that the resident presented with a diabetic food injury; however, there was no indication that R1 developed a Stage 3 pressure injury. The facility wanted R1 to go to hospital or a skilled nursing facility (SNF) to have the injury heal and then allow the resident to return to the facility. Administrator Pink confirmed that R1 returned to the facility on 02/06/2023.

Although the R1 presented with a diabetic ulcer on their left leg, the facility did their due diligence in sending
the resident out for evaluation. But, based on interviews, the facility did not want to accept the resident back,
thus, abandoning R1 at the hospital for two (2) days until an outside agency was able to intervene, at which time R1 was allowed to return on 02/06/2023.

Based on evidence gathered during the investigation, the allegation facility abandoned resident is deemed
substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited
(refer to LIC 9099-D).
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230206132519
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: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/08/2023
Section Cited
CCR
87468.1(a)(2)
1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will conduct all staff training on Personal Rights to all staff and submit documentation and attendees to CCL by 02/15/2023.
8
9
10
11
12
13
14
Based on interviews, the licensee did not
comply with the section cited above as
the facility abandoned R1 for 2 days at the hospital which poses an immediate health, safety and personal rights risk to resident 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: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/06/2023 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20230206132519

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: 57DATE:
02/07/2023
UNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Tillman PinkTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal eviction
Facility failed to return resident’s personal belongings
Facility failed to issue a refund
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Angel Ascencio conducted an intial complaint visit to the above facility. LPA met with staff member at 10:13 a.m. LPA Ascencio met with Administrator Tillman Pink at 1: 15 p.m. Entrance interview conducted.

On 02/06/2023, the Department received a complaint alleging an illegal eviction, facility failed to return resident's personal belongings and facility failed to issue a refund. On 02/07/2023, starting at 10:29 a.m. interview with Resident #1 (R1) revealed that R1 was sent to the hospital on 02/03/2023 for a wound on their leg. R1 was at the hospital for two (2) days and returned to the facility on 02/06/2023. Interview with Case Worker at 8:11 a.m., Outside Agency at 12:41 p.m., and Administrator Tillman Pink at 1:15 p.m., confirmed the return of R1. Addtionally, Administrator stated they were not planning on issuing an eviction notice to the resident. Based on evidence gathered, the allegation is deemed unsubstantiated at this time.
Continued on LIC 9099 - C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230206132519
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: 02/07/2023
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
Regarding the allegation facility failed to return resident’s personal belongings. Interview with R1 on 02/07/2023 starting at 10:29 a.m. revealed that R1 was worried about their personal belongings when admitted to the hospital. Further interview with R1 stated that the facility locked the door to their room. Later that same day, interview with Administrator Pink starting at 1:15 p.m. confirmed what R1 stated. Thus, the allegation of facility failed to return resident's personal belongings is deemed unsubstantiated.

Lastly, regarding the Facility failed to issue a refund. During interview with R1 at 10:29 a.m., R1 stated that the facility was paid for the January and February months. R1 lastly added that they have not requested a refund from the facility. Based on evidence gathered, the allegation is deemed unsubstantiated at this time.


Exit interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5