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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 10/09/2024
Date Signed: 10/24/2024 11:56:24 AM


Document Has Been Signed on 10/24/2024 11:56 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/22/2024 03:40 PM

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

NARRATIVE
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This report has been amended to correct deficiencies from type B to type A.

Licensing Program Analysts (LPA), Valeria Conway, conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240311081755). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Upon arrival LPA met with Administrator, David Aguiniga and explained the reason for the visit.

During the Department’s investigation of complaint, the following deficiencies were observed:

Resident #1 (R1s) care with Star World Home Health began on 01/30/2024, the home health nurse reported a Stage 2 pressure injury on R1’s coccyx measuring 0.3x0.2x0.2cm. A Physician’s Order from Dr. David Wong recommended a Skilled Nursing visit one time a week for 3 weeks. Dr. Wong’s order stated the following, “Skilled Nurse to perform/demonstrate and instruct patient/caregiver regarding coccyx pressure ulcer as follows: cleanse with wound cleanser, pat dry, apply triad paste and leave open to air daily. Patient caregiver may perform treatment during non-Skilled Nurse visit days. Coccyx pressure ulcer will be healed with current treatment by 4 weeks. Wound will remain free from signs and symptoms of infection, or complications during the treatment period”. The administrator was made aware of and agreed to the treatment plan. The staff were not skilled professionals qualified to perform the treatment. R1’s pressure injury became progressively worse and by 03/01/2024, R1 was diagnosed with an unstageable pressure injury.

Continued on LIC 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
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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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: 10/09/2024
NARRATIVE
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Continued from LIC 809

There were no home health logs or staff notes available at the facility regarding R1’s home health care and treatment plan documenting all aspects of R1’s care.

R1’s Physician Report, dated 12/22/2023, indicated that R1 did not have the capacity for any self-care, required continuous bed care, was not able to transfer independently to and from bed, was non-ambulatory, and diagnosed with dementia. The facility did not submit an exception request for the prohibited condition “Resident who depends on others to perform all activities of daily living for them”.

Citations issued, exit interview, appeal rights given.

On 10/22/2024 At 3:51 p.m., LPA spoke to David Aguiniga to explain the reason for amended report. Copy of report was emailed to daguiniga@glenparkseniorliving.com. LPA requested the report to be sent back with signatures.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/24/2024 11:57 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/22/2024 03:42 PM

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
CCR
87609(b)(3)

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87609(b)(3) Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care... (3) The licensee informs the home health agency of any duties the regulations prohibit facility staff from performing...This requirement is not met as evidenced by:
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The licensee will submit planon how facility will ensure staff do not perform treatment which requires an appropriately skilled professional. Submit proof to CCL by POC due date
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Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff performed wound care treatment to R1’s pressure injury, which posed an immediate health and safety risk to residents in care.
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Type A
10/23/2024
Section Cited
CCR87631(a)(3)(B)

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87631Healing Wounds(a) Except... the licensee shall be permitted... a resident who has a healing wound...(3) Residents with a stage 1 or 2 pressure injury...an appropriately skilled... (B) All aspects... documented in the resident's file.This requirement is not met as evidenced by:
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The licensee will plan how facility will ensure all aspects of care by home health and staff are documented. Submit proof to CCL by POC due date
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Based on records review, the licensee did not comply with the section cited above. There were no home health logs or staff notes available for R1 at the facility, which posed an immediate health and safety risk to residents in care.
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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/24/2024 11:57 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/22/2024 03:43 PM

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
CCR
87615(a)(5)

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87615Prohibited Health Conditions (a) Persons who require health services for or have a health condition...shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform...This requirement is not met as evidenced by:
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The licensee will submit a plan how facility will ensure that exception requests will be submitted for residents with a prohibited health condition. Submit proof to CCL by POC due date

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Based on records review, the licensee did not comply with the section cited above. Facility admitted and retained R1 who had no capacity for self-care, without submitting an exception request for the prohibited health condition, which posed an immediate health and safety risk to residents in care.
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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4