197603165-5-15-2024-29-AS-KLOZ-D5PVSL-20240528164144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 05/14/2024
Date Signed: 05/15/2024 08:17:19 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
04/16/2024 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20240416111628

FACILITY NAME:	GLEN PARK AT VALLEY VILLAGE		FACILITY NUMBER:	197603165
ADMINISTRATOR:	MARILOU MENDOZA		FACILITY TYPE:	740
ADDRESS:	5527 LAUREL CANYON BLVD		TELEPHONE:	(818) 769-6626
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	100	CENSUS: 38	DATE:	05/14/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Marilou Mendoza		TIME COMPLETED:	02:46 PM

ALLEGATION(S):

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Facility staff are violating resident’s personal rights.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent visit to investigate the allegation listed above. The LPA met with the Executive Director (ED), Marilou Mendoza and explained the reason for the visit.

On 04/17/2024, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced 10-day visit to investigate the allegations listed above. The LPA met with the Executive Director (ED), Marilou Mendoza and explained the reason for the visit. At 10:35 a.m. The LPA interviewed the ED and requested documents pertinent to the investigation. At 11:34 a.m. the LPA interviewed the resident (R1).

Continues on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240416111628

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 05/14/2024

NARRATIVE

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Facility staff are violating resident’s personal rights.

On the allegation that the facility staff violated the personal rights of the resident (R1), the reporting party’s concern is that the facility staff searched R1’s dresser and night stand drawers without R1’ permission. The LPA interviewed R1 who stated that staff had searched the night stand and dresser by opening drawers without R1’s permission. The LPA interviewed the facility’s staff about the search of R1’s night stand drawers and dresser drawers; and the staff stated that they conducted a search of the dresser drawers due to a preceding incident that took place in the R1’s room, which prompted the search for safety reasons. However, the staff stated that they had not asked for permission from R1 for the search of the drawers.

Based on the information gathered through interviews, the staff searched the personal accommodations of R1 without permission. Therefore, the allegation of violation of personal rights, is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D).

Citations were issued. Exit interview was conducted. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240416111628

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/14/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/31/2024 Section Cited CCR 87468.2	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities. (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations …This requirement is not met as evidence by:	1 2 3 4 5 6 7	The ED will review the regulations on Residents’ Rights and will email the CCL department a statement of understanding and review of the regulation 87468.2- Additional Personal Rights of Residents in Privately Operated Facilities.
	8 9 10 11 12 13 14	Based on information obtained through interviews, the administrator searched R1’s dresser and nightstand drawers without prior permission, which poses a potential health, safety and personal rights risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
04/16/2024 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20240416111628

FACILITY NAME:	GLEN PARK AT VALLEY VILLAGE		FACILITY NUMBER:	197603165
ADMINISTRATOR:	MARILOU MENDOZA		FACILITY TYPE:	740
ADDRESS:	5527 LAUREL CANYON BLVD		TELEPHONE:	(818) 769-6626
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	100	CENSUS: 38	DATE:	05/14/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Marilou Mendoza		TIME COMPLETED:	02:46 PM

ALLEGATION(S):

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Facility staff retaliated against resident.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20240416111628

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 05/14/2024

NARRATIVE

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Facility staff retaliated against resident.

On the allegation that the facility staff retaliated against the resident, it is the concern of the reporting party that staff retaliated against the resident by taking away their personal hygiene items. The LPA interviewed R1 who stated that at some point during the search of a dresser drawer in their room being conducted by staff, the R1 witnessed the staff remove personal hygiene items from a dresser drawer, however the R1 added that they left the room at the point of the search. When the R1 returned to their room, R1 observed all the personal hygiene items neatly placed back inside the dresser drawer. The LPA interviewed the staff, who stated that they conducted a search of the dresser drawers due to a preceding incident that took place in the R1’s room, which prompted the search for safety reasons. The staff stated that they indeed had taken out the hygiene items out of the drawer, which they placed on top of the dresser. Once the search was completed, the staff placed back the hygiene items in the drawer, and never removed the items from the room.

Based on the information obtained from interviews, the interviews revealed that the items were not removed or taken away from R1’s room as a form of retaliation. Therefore, the allegation that the facility staff retaliated against resident, is deemed Unsubstantiated at this time.

No citations were issued. Exit interview was conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC9099 (FAS) - (06/04)

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