197603165-1-8-2026-29-AS-QHUH-DQ5TWV-20260108140611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 01/08/2026
Date Signed: 01/08/2026 02:06:27 PM

Document Has Been Signed on 01/08/2026 02:06 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 VILLAGE		FACILITY NUMBER:	197603165
ADMINISTRATOR/ DIRECTOR:	VIRGINIA SUMULONG		FACILITY TYPE:	740
ADDRESS:	5527 LAUREL CANYON BLVD		TELEPHONE:	(818) 769-6626
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY: 100		CENSUS: 46	DATE:	01/08/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:16 AM
MET WITH:	Virginia Sumulong - Executive Director		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced for a required one-year visit. The LPA arrived at 9:16AM and met with Interim Executive Director (ED) Virginia Sumulong. Entrance interview conducted. At 9:28AM, the LPA and ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a two-story building. The following was observed: RESIDENT ROOMS: The LPA observed eight (8) randomly selected rooms on the first and second floors and no immediate health or safety hazards were observed. Appropriate furniture was observed in the units including clean linens and sufficient lighting. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Water temperature was tested throughout the units and measured between 108.1 degrees F and 120.7 degrees F. Resident pull cord was tested with a staff response of less than one (1) minute. COMMON AREAS: On the first floor there was a lobby/reception area, administrative offices, medication room, two (2) visitor restrooms, laundry room, beauty shop, shower room, and two (2) courtyards. On the second floor there was an activity room, library, two (2) visitor restrooms, staff lounge, and laundry room that contained extra linens. All required rooms were secured and inaccessible to residents. LPA Huynh observed all common areas to be clean, clear of obstructions, and furniture were in good condition. Required posting were observed on the first floor hallway and no bodies of water were observed. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
	VISIT DATE: 01/08/2026

NARRATIVE

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KITCHEN/DINING ROOM: The main kitchen is located on the first floor and attached to the dining room. Facility dining room and kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries which occur every Friday. There was a sufficient supply of perishable and non-perishable food. The LPA observed the refrigerators and freezers with food to be of good quality and labeled with expiration dates. An extra pantry was located in the rear of the building inside an unattached shed that contained non-perishable items and an extra freezer containing frozen meat. Emergency food and water were stored in supply closets near the kitchen.

OUTSIDE: The facility had a rear patio with various tables and chairs for resident use. The furniture were in good condition. The perimeter of the facility was secured with two (2) remote driveway gates with built in doors. The rear of the facility also had parking spaces for staff and visitors.

RECORDS: Resident records were reviewed at 10:17AM. LPA Huynh reviewed six (6) files for, but not limited to admissions agreements, medical assessment, appraisals, and consent forms. Resident records reviewed were in order at this time. The LPA reviewed six (6) personnel records for, but not limited to job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and appropriate trainings. Staff files reviewed were in compliance with regulation at this time. The LPA discussed with the ED about ensuring all in-service staff training contains the duration of the training completed.

INFECTION CONTROL/EMERGENCY DISASTER: The LPA reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPA noted that the facility is in compliance with regulation with both plans reviewed annually. The facility conducts emergency disaster drills monthly, with the last drill documented on 12/30/2025. Fire extinguishers were observed throughout the facility and last serviced on 10/10/2025. Fire systems are inspected annually with the last inspection on 10/10/2025 by Fox Fire Life and Safety Inc.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 01/08/2026

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	MEDICATION: Medication review began at 1:03PM. The LPA reviewed medications for five (5) residents. Medications were maintained locked inaccessible to residents on the first floor. Resident medications reviewed were documented and stored in compliance with regulation at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

LIC809 (FAS) - (06/04)

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