197603165-5-15-2024-29-AS-DPEA-D5RPZZ-20240530114622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 05/15/2024
Date Signed: 05/15/2024 05:24:42 PM

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
02/07/2023 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20230207083249

FACILITY NAME:	GLEN PARK AT VALLEY VILLAGE		FACILITY NUMBER:	197603165
ADMINISTRATOR:	TILLMAN PINK		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:	05/15/2024
		UNANNOUNCED	TIME BEGAN:	01:03 PM
MET WITH:	Marilou Mendoza		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Facility staff did not notice resident’s absence

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings on the above noted allegation. LPA met with administrator Marilou Mendoza and explained the reason for the visit.

On 02/7/2023, LPA Angel Asencio conducted an initial complaint investigation visit. LPA Ascencio interviewed staff and obtained pertinent documents regarding resident 1 (R1). LPA Ascencio also interviewed the nurse case manager for R1 on 2/7/2023.

R1’s physician’s report indicated R1 was able to leave the facility unsupervised. LPA Ascencio obtained copies of the “Resident Sign In & Out” sheets for 1/10/2023, 1/11/2023, and 1/17/2023. R1 signed out on 1/10/2023 at 11:40 a.m. and signed back in at 10:30 p.m. R1 signed out on 1/11/2023 at 1:20 p.m. and

(continued on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 29-AS-20230207083249

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: 05/15/2024

NARRATIVE

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(continued from LIC9099)

signed back in at 3:07 p.m. R1 signed out on 1/17/2023 at 4:16 p.m. and never signed back in. The facility’s house rules indicate on rule number four that all residents must sign out and sign in upon return to the facility.

A nurse came to the facility to meet with R1 on 2/2/2023, but R1 was not there. The receptionist told the nurse R1 had left that morning and she did not know when R1 would be returning. The nurse asked R1’s roommate about R1’s whereabouts and the roommate informed the nurse R1 had not returned to the facility for weeks. On 2/3/2023, the nurse conducted a medical eligibility search for R1 and discovered R1 had been reported deceased. The nurse then called the facility, spoke with the receptionist and asked to speak with R1. The receptionist told the nurse R1 was visiting their family member and did not know when R1 would return to the facility. The nurse then informed the receptionist that R1 had been reported deceased. The receptionist called the nurse back later and stated that R1 had signed out on 1/17/2023 and did not return to the facility. R1’s family stated R1 passed away on 1/19/2023 at a friend’s house. The receptionist explained that they had mistaken another resident for R1 when they told the nurse they had seen R1 on 2/2/2023.

The nurse contacted R1’s family who informed the nurse R1 was deceased. R1 had gone to visit a friend on 1/17/2023 and passed away at the friend’s house on 1/19/2023. The facility had been unaware of R1’s whereabouts from 1/17/2023 until they received notification of R1’s death on 2/3/2023. The administrator at that time, Tillman Pink, submitted a death report on 2/7/2023 stating they were informed of R1’s 1/19/2023 death by R1’s family on 2/3/2023.

Based on the information gathered from interviews and record review, the facility staff did not know the whereabouts of R1 for nearly three weeks. They did not review the sign-in/out sheet to follow-up on anyone who had not signed back in. Therefore, the allegation facility staff did not notice resident’s absence is deemed Substantiated at this time.

The following deficiencies were observed (see LIC9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted with administrator. A copy of this report with appeal rights provided to administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230207083249

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: 05/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/22/2024 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	§1569.312(a)Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a Plan of Action, documenting how the facility will follow-up with residents who do not sign back in after an outing to ensure residents are provided appropriate care and supervision. Submit plan to CCL on or before 5/22/2024.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as the licensee failed to provide adequate supervision to R1 who signed out of the facility and never returned, which posed an immediate health and safety risk to residents 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: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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