197603165-5-15-2024-29-AS-DPEA-D5RQD7-20240530120416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 05/15/2024
Date Signed: 05/15/2024 05:23:19 PM

Unsubstantiated

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
06/30/2023 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230630155629

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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Staff steal resident's medications.
Staff falsify residents' medication records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met with administrator Marilou Mendoza and explained the reason for the visit.

On 7/6/2023, LPA Angel Ascencio conducted an initial complaint investigation visit. During that visit LPA Ascencio interviewed three staff and conducted a medication audit of seven randomly chosen residents. LPA Ascencio found one resident’s medications had not yet been logged on the centrally stored medication and destruction record (CSMDR). The resident had a medication change mid-cycle and staff had not yet logged the medications on the CSMDR, however it appeared the resident was receiving their medications as prescribed. This error was addressed that day in a Case Management - Deficiencies visit. Otherwise, all the other medications were logged and appeared to be given as prescribed.

(continued on LIC 9099-C)

Unsubstantiated

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)

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Control Number 29-AS-20230630155629

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 LIC 9099)

During LPA Camara’s visit on 5/15/2024, LPA interviewed staff at 1:10 p.m., 1:25 p.m., 1:30 p.m. and 1:44 p.m. LPA reviewed records at 1:37 p.m. for former resident 1 (R1).

LPA Camara discovered the facility did not maintain all records for R1; medication records were missing. In addition, personnel records for former staff 1 (S1) and staff 2 (S2) were also missing. These missing records were addressed on a Case Management - Deficiencies visit on 5/15/2024.

Based on interviews, a medication audit and record review, LPAs could not find evidence of residents’ medications being stolen nor was there any indication staff falsify medication records. Therefore, these allegations are deemed Unsubstantiated at this time.

Exit interview conducted and report issued.

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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