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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 03/12/2024
Date Signed: 03/12/2024 04:09:45 PM


Document Has Been Signed on 03/12/2024 04:09 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
WOODLAND HILLS N.ASC, 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: 38DATE:
03/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Marilou Mendoza and Virginia SumulongTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Valeria Conway and Zabel Chochian conducted an unannounced Case management deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20240311081755.

During the complaint investigation LPAs conducted a physical plan tour of the facility with Assistant Administrator from 10:00 a.m. to 11:15 a.m. to ensure there are no health and safety hazards and the following deficiencies were observed. During the physical plan tour LPAs met with Resident #1 (R1). R1 expressed concerns about wheelchair provided not having enough support and causing resident discomfort. Based on interview with R1, record review and interview with Assistant Administrator it was revealed that two (2) prescriptions for a new wheelchair from primary physician were issued since December 2023. As of today, R1 has not received a new wheelchair prescribed by physician. At approximately 10:25 a.m. LPAs observed Laundry room in second floor was unlocked and cabinets in the laundry room containing detergents, and chemical supplies were unlocked, unsupervised and accessible to residents. Also during the tour at approximately 11:02 a.m. LPAs observed Resident's 2 (R2) Room #11 door was wide open, nobody in the room at the time. LPAs observed resident's hygiene products/items such us body lotion and hand cream on a table along side the wall. Also, on top the night stand next to resident's bed LPAs discovered a container with scissors accessible to other residents. Although R1 is able to store personal hygiene items and not at risk, based on random records reviewed and interview with Administrators other residents are.

Based on records review and the information obtained, the following deficiencies were observed. Pursuant to Title 22 of the CA Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 809-D)

Exit interview conducted with Administrators. Today's reports, and appeal rights were discussed, and copy was provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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 03/12/2024 04:09 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: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2024
Section Cited
CCR
87309(a)

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Storage Space: Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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Administrators agreed to provide in service training to staff and discuss with residents the importance of keeping personal items, which pose a dangerous to clients when accessible before POC due date.
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Based on observations, licensee did not comply with section above by not ensuring detergents, cleaning solutions and scissors are kept inaccessible to residents. This poses an immediate risk to residents in care.
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Type B
03/29/2024
Section Cited
CCR80072(a)(2)

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Personal Rights: Except for children’s..., each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations...and equipment to meet his/her needs.This requirement is not met as evidenced by:
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Administrators agreed to follow up with medical supply company by upcoming Friday and have proof of outcome or resolution to R1 needs before POC due date
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Based on record review and interviews, licensee did not comply with section above. R1's prescription order dated on 12/14/2023 and _____ for new wheelchair was not processed in a timely manner. This poses a potential risk to 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2