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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 01/31/2024
Date Signed: 01/31/2024 02:09:30 PM


Document Has Been Signed on 01/31/2024 02:09 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:GLEN PARK AT VALLEY VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:MARILOU MENDOZAFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 37DATE:
01/31/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marilou Mendoza, Administrator & Virgina Gigi Sumulong, Assistant AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Zabel Chochian responded to the facility to conduct a case management visit in response to the SOC341 submitted by the facility Administrator on 01/30/24. Upon arrival LPA met with Administrator Marilou Mendoza and Assistant Administrator Virgina Sumulong. Reason for visit was explained.

The SOC341 indicated that Resident #1 (R1) alleged that they were sexually assaulted two-weeks ago by another facility resident (R2).

An SOC 341 was also submitted by facility Administrator to Adult Protective Services (APS), Local Long Term Care Ombudsman (LTCO) and local law enforcement. Facility Administrator stated that she is currently working on submitting the incident report to Community Care Licensing (CCL). Administrator stated that Law Enforcement will be visiting facility today and once she gathers additional information she will submit the incident report to CCL.

During today's visit, the LPA completed a brief physical plant tour, discussed case with Administrators and obtained copies of R1 and R2’s records. The Administrator was notified that this incident was referred to Community Care Licensing Investigation's Branch (IB) and assigned to Special Investigator Laarni Santiago and that further investigation is required.

Exit Interview conducted and copy of report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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