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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 05/15/2024
Date Signed: 05/15/2024 05:21:51 PM


Document Has Been Signed on 05/15/2024 05:21 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:
05/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Marilou MendozaTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Deficiencies visit to the above facility. LPA met with administrator Marilou Mendoza and explained the reason for this visit.

During today's visit, 5/15/2024, LPA requested medication records for resident 1 (R1) who no longer resides at the facility. R1 moved out on 8/4/2023. Assistant Administrator Gigi Sumulong located R1's records but there were no medication records. These records must be maintained at the facility a minimum of one year.

LPA requested personnel records for two former employees, staff 1 (S1) and staff 2 (S2), who were reportedly terminated in 2023. The Assistant Administrator attempted to locate the personnel records for these two employees. She looked through records in storage but could not locate them. These records must be maintained at the facility for a minimum of three years following termination of employment.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited
(refer to LIC 809-D).

Exit interview conducted. A copy of this report and appeal rights were provided to the Administrator.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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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Document Has Been Signed on 05/15/2024 05:21 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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
CCR
87465(h)(6)

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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...
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Licensee will submit a Plan of Action, documenting how the facility will maintain medication records. Submit plan to CCL on or before 5/22/2024.
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This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the licensee failed to keep medication records for R1, which posed a potential health and safety risk to residents in care.
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Type B
05/22/2024
Section Cited
CCR87412(h)

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87412 Personnel Records
(h) All personnel records shall be retained for at least three (3) years following termination of employment.
This requirement is not met as evidenced by:
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Licensee will submit a Plan of Action, documenting how the facility will maintain personnel records of ex-employees. Submit plan to CCL on or before 5/22/2024.
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Based on interviews and record review, the licensee did not comply with the section cited above as the licensee failed to keep personnel records for S1 and S2, which posed a potential health and safety 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) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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