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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 02/10/2023
Date Signed: 02/10/2023 01:01:51 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
12/03/2020 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20201203113354
FACILITY NAME:GLEN PARK AT VALLEY VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:PINK TILLMANFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 57DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessyca MunozTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Family member was not notified of resident's hospitalization.
INVESTIGATION FINDINGS:
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On 02/10/2023, Licensing Program Analyst (LPA), Sandra Urena, conducted an unannounced subsequent visit to further investigate the allegations listed above. LPA Urena met with staff at 10:00 a.m., and explained the reason for the visit. The staff contacted Administrators to inform them of the visit. Administrators were not able to be present for the visit. Facility representative to sign off on today's complaint report.

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 04:30pm with Elizabeth Flores, the facility Assistant Administrator. Between 4:30pm - 5pm LPA conducted telephone interviews with the administrator and a video call which consisted of a review of physical plant. 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. Further investigation is required at this time.
Continues on LIC9099C..
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: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
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-20201203113354
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: 02/10/2023
NARRATIVE
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On 02/07/2023, LPA Urena conducted a facility folder review in the CCLD Server system to locate the Unusual Incident/Injury Report (LIC 624) pertaining to R1’s hospitalization on 10/23/2020, and to review the section ‘AGENCIES/INDIVIDUALS NOTIFIED’. The results were negative, as the LPA after an extensive search, could not locate a report pertaining to the hospitalization of R1, consequently the CCLD office didn't receive an Incident Report. However, LPA Urena did locate a Death Report (LIC 624A) dated 10/29/2020, and submitted by S1 to CCLD via fax; which describes that the Social Worker for the SNF contacted Glen Park at the Valley Village on 10/28/2020, and spoke with the med tech to inform them of the passing of R1, and to request the name of the family's member phone number to notify the family. Additionally, LPA Urena conducted a file review of R1’s documents emailed by the facility to LPA Basili. The record review revealed that the emergency information form (LIC 601) listed the next of kin, and name of nearest relative of R1. On 02/10/2023, at 10:20 a.m., LPA Urena interviewed S1, and requested all LIC’s 624 related to R1 during their stay at the facility. The interview revealed that according to S1's recollection, the family was informed about R1 going to the hospital. Staff was unable to provide file for R1, due to not having a relief staff, and documents not being within reach.


Based on the information obtained, and record review, there is sufficient evidence to substantiate the allegation that the facility did not inform the family members, and the CCLD about R1 being hospitalized on 10/23/2020. Therefore, the 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: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20201203113354
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: 02/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
02/17/2023
Section Cited
CCR
87211(a)(1)(D
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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) Inform the CCLD that the Licensee has reviewed the regulation related to reporting requirements and self certify via a letter that they have completed the review, and submit proof via a self-certification letter to CCLD by 01/17/2023.
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Based on record review, and interviews, the licensee did not comply with the section cited above, as family members and CCLD were not informed of R1’s hospitalization, 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: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
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
12/03/2020 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20201203113354

FACILITY NAME:GLEN PARK AT VALLEY VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:PINK TILLMANFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 57DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessyca MunozTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff did not return all of the resident's belongings to the family member.
INVESTIGATION FINDINGS:
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On 02/10/2023, Licensing Program Analyst (LPA), Sandra Urena, conducted an unannounced subsequent visit to further investigate the allegations listed above. LPA Urena met with staff at 10:00 a.m., and explained the reason for the visit. The staff contacted Administrators to inform them of the visit.

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 04:30pm with Elizabeth Flores, the facility Assistant Administrator. Between 4:30pm - 5pm LPA conducted telephone interviews with the administrator and a video call which consisted of a review of physical plant. 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. Further investigation is required at this time.
Continues on LIC 9099-A C...
Unsubstantiated
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: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
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-20201203113354
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: 02/10/2023
NARRATIVE
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On the allegation that ‘Staff did not return all of the resident's belongings to the family member’; it is the concern of the complainant that the facility did not return to the family members, R1’s writings, and a recorder when asked (the resident did a lot of writing and had a recorder), and the facility staff only sent the family members an envelope with three letters. To investigate the allegation, LPA Basili interviewed the family members on 10/28/2020 about R1’s belongings. The family members stated that as of the date of the interview, they had not received R1’s belongings (R1’s writings and a recorder), all they received was an envelope. LPA Basili interviewed the administrator on 12/23/2020 and the administrator stated that they believed that the family member received all the belongings that they wanted to keep. The administrator does not recall seeing a box filled writings or a recorder.

LPA Urena conducted a file review of R1’s documents emailed by the facility administrator to LPA Basili. The record review revealed that a Client/Resident Personal Property and Valuables Form (LIC 621) was filled out, and signed by R1 on the day of admission to the facility on 10/16/2012. The list of personal items list does not have a recorder as part of the items. Additionally, a Personal Property Inventory form was filled out, and signed by R1 on 02/18/2014. The inventory sheet lists three (3) packs of socks, four (4) regular waist jeans, and three (3) polo shirts. On 02/10/2023, LPA Urena interviewed S1 about R1 belongings, and S1 stated that according to their recollection, the family received all of R1's belongings, but could not specify what belongings. Staff was unable to provide file for R1, due to not having a relief staff, and documents not within reach.

Based on the file review, there is insufficient evidence that the writings and a recorder were part of R1’s personal property and valuables. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5