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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 08/22/2024
Date Signed: 08/22/2024 02:34:02 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/21/2023 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20230321141523
FACILITY NAME:GLEN PARK AT VALLEY VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:TILLMAN PINKFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 40DATE:
08/22/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marilou MendozaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not prevent a resident from causing harm to other residents while in care

Staff did not meet the medical needs of the residents while in care

Staff did not properly report incident involving residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. for the above allegation. During today’s visit, LPA met with Executive Director Marilou Mendoza and explained the reason for the visit.

On 3/30/2023, the initial complaint visit was conducted by LPA’s Angel Ascencio and Sandra Urena between approximately 09:35 a.m. - 4:15 p.m. During the visit, LPA’s conducted physical plant, interviewed staff, residents, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 06/26/2024, LPA Brian Balisi conducted a subsequent visit between approximately 01:00 p.m. – 3:30 p.m. During the visit, LPA conducted physical plant, interviewed staff, residents and reviewed and obtained copies of pertinent documents relevant to the investigation. Today LPA conducted physical plant, interviewed staff and conducted medication audit.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
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-20230321141523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT VALLEY VILLAGE
FACILITY NUMBER: 197603165
VISIT DATE: 08/22/2024
NARRATIVE
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Continued from 9099
It was reported that “Staff do not prevent a resident from causing harm to other residents while in care”, as it was alleged that that due to lack of staff supervision Resident #1 (R1) and Resident #2(R2) were physically assaulted by Resident #3(R3) on separate occasions. R2 and R3 were roommates during the time of the complaint. On 02/22/2023, at approx 4 p.m. R2 and R3 were reported to have an argument in their shared room, which resulted in R3 striking R2 with a cane on their face. R2 immediately went downstairs to Staff and received first aid then was admitted into a local hospital. It was also reported that R3 kicked R1 on the back of their wheelchair. LPA's interview with R1 revealed they do not recall their wheel chair being kicked by R3 or having any physical altercation with any resident at this time. LPA's interview with six (6) residents in care who resided at the facility at the time of the complaint revealed that all six (6) residents did not express any potential or immediate concerns for being involved in a physical altercation due to lack of staff supervision. Furthermore interviews with all (6) residents stated they have always observed staff intervene when residents were observed to be overly aggressive with other residents. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not prevent a resident from causing harm to other residents while in care” is deemed Unsubstantiated at this time.

It was reported that “Staff did not meet the medical needs of the residents while in care”, as it was alleged that a med tech was not available to administer medications on 03/13/2023. It was also stated that a med tech not being available has occurred on multiple occasions. Interviews conducted and records review revealed that there is at least one (1) med tech per shift with five (5) med techs on staff along with an LVN. Interviews conducted with six (6) residents in care who resided at the facility at the time of the complaint revealed that four (4) out of the six (6) residents interviewed have never missed a medication dosage due to a med tech not being available. LPA's interview with two (2) out of the (6) residents revealed they have not experienced missing a dosage of medication due to a med tech not being available, however they have experienced a delay in receiving their medications due to a med tech arriving late to work. Those (2) residents continued to state it does not occur often and they recall they did not have to wait more than 30 mins from their typical time of administration. LPA's records review of six (6) resident Medication Administrator Records (MARS) dated 03/13/2023 revealed that all (6) residents received their medications as prescribed..
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230321141523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT VALLEY VILLAGE
FACILITY NUMBER: 197603165
VISIT DATE: 08/22/2024
NARRATIVE
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Continued from 9099-C
On 08/22/2024, LPA conducted a medication review for five (5) randomly selected residents in care. Medication review revealed that medications are centrally stored in the med room next to the front desk. All medications reviewed were observed to be administered as prescribed at this time. Additionally, LPA’s interview with the Executive Director revealed there are (5) med techs on the schedule along with the receptionist, the activity director and the Assistant Administrator who are each certified for medication pass. If there is a call out or a delay in one of the staff’s arrivals, any one of the trained staff would take over for medication pass. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not meet the medical needs of the residents while in care” is deemed Unsubstantiated at this time.

It was reported that “staff did not properly report incident involving residents”, as it was alleged that staff do not contact the proper emergency personnel when situations arise. Interviews conducted with six (6) residents in care who resided at the facility at the time of the complaint revealed that all six (6) residents did not express any potential or immediate concerns for staff not contacting the proper emergency personnel if emergency situations were to arise. Furthermore all (6) residents have always observed staff address resident concerns or emergency situations in a timely manner. In addition, LPA's interview with five (5) staff revealed that when any staff observes a medical emergency or other emergency situations the med tech is informed right away. Med techs then assess the situation and contact proper authorities. All (5) staff also stated they have always observed staff to address any emergency situations in a timely manner. LPA’s records review of Incident reports (LIC 624) from July 1st 2024 to August 2024 revealed either 911 or a Non-Emergency medical transport was called approx. seventeen (17) times for various resident related emergencies or needs. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not properly report incident involving residents” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3