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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 03/30/2023
Date Signed: 03/30/2023 03:55:35 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
02/09/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20210209095613
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:
03/30/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessyca MunozTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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On 03/30/2023, Licensing Program Analysts(LPA) Sandra Urena, and Angel Ascencio conducted an unannounced subsequent visit to investigate the allegation above. The LPAs arrived at 10:00 a.m., and spoke with receptionist Jessyca Munoz and explained the reason for the visit. Administrator Tillman Pink was not available.

At 10:36 a.m., the LPAs conducted residents and staff interviews; and from 11:25 a.m. to 11:45 a.m. conducted an initial medication audit. LPAs returned to finalize the medication audit from 1:30 p.m to 2:15 p.m.


Continues on LIC9099...
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: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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 4
Control Number 29-AS-20210209095613
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: 03/30/2023
NARRATIVE
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On 02/11/2021, Licensing Program Analyst (LPA) Brian Balisi initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically at 11:00am with Elizabeth Flores, the facility Assistant Administrator. Between 12:30pm - 1pm LPA Basili 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. On 2/12/2021, LPA Basili interviewed the complainant at 11:15am, and interviewed Administrator Elizabeth Flores between 12:30 p.m. to 1:00 p.m.

On the allegation that the ‘Staff mismanaged resident's medication’; it is the complainant’s concern that on 01/23/2021, they went to the facility to pick up R1’s medication. The facility staff gave the complainant R1’s medications, and complainant was not asked to sign for the medications they received. Complainant took the medications to the hospital, and hospital staff found out that the facility staff gave the complainant another resident’s(R2) medication. To investigate the allegation LPA Urena interviewed the complainant on 03/10/2023 from 11:40 a.m. to 12:16 p.m. The interview revealed that one bottle of medicine for R2, was included in the bag of medicines for R1. LPA Basili interviewed Administrator Elizabeth Flores regarding contact protocols for residents being medication management. In regard to medication, the Administrator stated that they were informed by staff that R1’s POA came in to grab R1’s medication so they could take it to R1 in the hospital. Administrator was told by staff they gave them the medication. Assistant Administrator was not present at the time POA came to retrieve the medication.

On 03/30/2023, LPA Urena interviewed staff #2(S2) and asked about the process for release of medication. The S2 stated that they use a form named Medication Transfer Sheet/Release of Responsible to release medication. LPAs Urena and Ascencio interviewed seven residents about assistance with their medication by the facilities med techs. Two out of seven residents stated that they had received medication that did not belong to them. The LPAs asked how they(residents) knew that the pills (medication) did not belong to them? R3 stated, ‘I know my pills, and I said to the med tech, I don’t take this, and I don’t recognize the pills’. R4 stated, ‘They gave me pills that didn’t belong to me, I told the med tech right away that they were not mine’.

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

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20210209095613
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: 03/30/2023
NARRATIVE
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The LPAs conducted a medication audit for 57 residents, and the LPAs found one medication box (Methylprednisolone, 4mg), filed away under a wrong resident’s label. Per S2, the box of the medication did not fit in the assigned (labeled) for resident #8(R8). Additionally, the LPAs noticed that for resident #9(R9), the medication in the drawer did not have a divider nor label with R9’s name; for resident #10 (10) the divider was missing resident’s name.

Based on the information obtained through interviews and record review, there is enough evidence to support the allegation that ‘Staff mismanaged resident's medication’. Therefore, this allegation is deemed Substantiated 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.



Citation was issued. Exit interview was conducted with Quality Assurance Director, Rafael Silva. A copy of the report and Appeal Rights were issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20210209095613
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: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/07/2023
Section Cited
CCR
87465
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87465(h)(2)Incidental Medical and Dental CareThe following requirements shall apply to medications which are centrally stored: ...shall be kept in a safe and locked place that is not accessible to persons other than employees …centrally stored medication. This requirement is not met
as evidenced by:
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Licensee agrees to conduct staff training to ensure that residents medications are not missmanaged. Proof of training, sign in sheets, and supportive documentaion must be sent to LPA by 04/07/2023.
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Based on interviews and observation the licensee did not comply with the section cited above, as R2’s medication was mixed with R1’s medication, 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: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4