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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 10/05/2023
Date Signed: 10/05/2023 04:32:34 PM


Document Has Been Signed on 10/05/2023 04:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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: 39DATE:
10/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Virginia Sumulong, Asst AdministratorTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to deficiency observed during a visit to the facility today. LPA Yee met with Virginia Sumulong, Assistant Administrator. Rafael Silva, Administrator was also at the facility during the visit.

Per review of the staff roster, staff file at 2:14pm, Guardian document provided during today's visit, Virginia Sumulong, who is also known as Virginia De Los Reyes was hired on 9/18/23 and has been present and working at the facility from September 18, 2023 through October 5, 2023 without being associated to the facility. The Administrator was made aware that Virginia Sumulong was not listed on the Personnel Report printed on 10/2/23 and he indicated that he would have to go on to Guardian to determine what happened. A report was provided to LPA Yee by the Administrator that indicated that Virginia De Los Reyes was previously associated to the facility on 5/4/2011 and disassociated on 4/3/23. Per verification with Licensing personnel, the association for Virginia De Los Reyes was completed today (10/5/23). The facility failed to ensure that Virginia was cleared and associated to the facility prior to being present at the facility from 9/18/23-10/5/23.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. CIVIL PENALTIES were assessed.

Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was given.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/05/2023 04:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2023
Section Cited
CCR
87355(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
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The Licensee will ensure that all staff, volunteers or individuals who are subject to a criminal record clearance have received a criminal record clearance and are associated to the facility prior to being present at the facility at all times.
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Per record review, Virginia Sumulong, aslo known as Virginia De Los Reyes, hired on 9/18/23, has been employed and present at the facility and has not been associated to the facility until it was brought to the Admnistrator's attention today-10/5/23. CIVIL PENALTIES of $500 were assessed
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Virginia Sumulong was associated to the facility under the name of Virginia De Los Reyes through Guardian during the visit today.
***corrected at the time of the visit****

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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2