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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 01/04/2023
Date Signed: 01/04/2023 03:11:11 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
09/21/2020 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20200921143746
FACILITY NAME:GLEN PARK AT VALLEY VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:RAFAEL SILVAFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 54DATE:
01/04/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Janyce PinkTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not report incidents to the department in a timely manner.
INVESTIGATION FINDINGS:
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On 01/04/2023, Licensing Program Analysts (LPAs), Sandra Urena, and Ashley Smith conducted an unannounced subsequent visit to deliver the findings for allegation listed above. The LPAs met with Janyce Pink, and explained the reason for the visit.

On 09/30/2020, Licensing Program Analyst (LPA) Brian Balisi initiated a complaint investigation for the allegations 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 at 03:45pm with Elizabeth Flores, the facility administrator. Between 3:45pm - 4:15pm LPA conducted telephone interview with the administrator. LPA also requested copies of Census, Staff schedule, admission agreement and resident documentation relevant to the investigation, to be emailed to the LPA by end of business day today.

Continues on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
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 3
Control Number 29-AS-20200921143746
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: 01/04/2023
NARRATIVE
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On the allegation that facility ‘Staff did not report incidents to the department in a timely manner’, the complainant’s concern is that the facility staff are not submitting Special Incidents Report(SIR’s) to reporting agencies or to residents’ responsible parties in a timely manner, and sometimes staff do not report incidents at all. To investigate this allegation, on 09/30/2020, LPA Basili interviewed Staff #1(S1). Per the interview, S1 stated, ‘That sometimes they have had a difficult time faxing / emailing any documents to numerous agencies. They have had to sit by the fax or wait by the computer while on the phone with any individual to confirm they have received the document. They would not be surprised if there is someone that is missing documents, that they believed they had sent out; however, they do keep all the hard copies on file’. On 01/03/2023, LPA Urena conducted a record review. The record review revealed that the licensee had three Incident Reports (SIR’s) drafted regarding incidents, which occurred on the following dates: 9/17/2020 for Seizure; 09/23/2020 for Psych Evaluation, and 09/24/2020 for Psych Evaluation. However, the licensee did not submit the drafted incident reports to CCLD as verified on the CCLD’s electronic filing system by LPA Urena on 01/03/2023.

During today's visit the LPAs spoke with S2 about two current positive cases of COVID at the facility which occurred on 12/25/2022, and 12/28/2022. According to the administrator, and the receptionist both cases were reported to the CCLD, however, only one case was received at the CCLD office via fax on 12/29/2022.

Based on the information obtained, there is sufficient evidence to support the claim that ‘Staff did not report incidents to the department in a timely manner’. Therefore, 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.

Citations were issued. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20200921143746
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: 01/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
01/13/2023
Section Cited
CCR
87211
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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:
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The licensee has agreed to do the following:
1) Conduct staff training on incident reporting and submit proof to CCLD by 01/13/2023.

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Based on record review, the licensee did not comply with the section cited above, as reports were not submitted for incidents to both CCL and Regional Center, which poses a potential health and safety risk for residents 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
LIC9099 (FAS) - (06/04)
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