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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 02/04/2021
Date Signed: 05/04/2021 08:05:21 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2020 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20200213125706
FACILITY NAME:GLEN PARK AT VALLEY VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:PINK, JR, TILLMANFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 40DATE:
02/04/2021
UNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Tillman Pink III - AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident contracted communicable disease while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit with Administrator Tillman Pink III to deliver the findings for the above allegation. Due to the situation surrounding the Corona Virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted via Virtual platform.

Entrance interview conducted.

On 02-13-2020, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator Denis Seng.

On 02/13/2020 at 2:30 PM, LPA Manya Lefian, initiated the complaint visit. LPA interviewed facility staff and obtained copies of the facility records. (continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021
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 5
Control Number 31-AS-20200213125706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GLEN PARK AT VALLEY VILLAGE
FACILITY NUMBER: 197603165
VISIT DATE: 02/04/2021
NARRATIVE
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(continued from LIC 9099)

During the course of the investigation, Investigator Seng interviewed residents on 03/12/2020, facility staff on 03/04/2020, family member, medical professionals and experts in their field on different dates. Investigator Seng also requested and reviewed police reports, hospital medical records and other relevant records.

LPA’s record review revealed that Resident #1 (R1) was admitted at the facility on November 2018. The preplacement appraisal was signed on 10/30/2018. The physician’s report dated 11/06/18 was reviewed and revealed that R1 needed some assistance on bathing, grooming and toileting needs.

Investigator Seng interviewed family member of R1 on 12/11/2020. The interview revealed that R1 left the facility on the following dates after 10/01/19, from 09/25/19 to 10/01/19 R1 was confined at the Acute Care hospital and then proceeded to a Skilled Nursing Facility from 10/01/19 to 10/16/2019.

On 10/22/2019, R1 had a medical appointment with R1’s cardiologist and on 10/23/2019 was transported to the hospital via an ambulance.

On 01/28/2020, R1 went with a family friend for another medical appointment.

Investigator Seng conducted a facility records review, it showed that R1 last left the facility on 03/02/19 at 1:45 PM and was visited by R1’s family member on 11/03/19, 11/09/19, 11/16/19, 11/23/19, 11/28/19, 12/08/19 and 12/15/19. R1 was hospitalized on 02/11/2020 and was diagnosed with a communicable disease. The resident had no prior medical history of a communicable disease.

Investigator Seng interviewed a medical professional on 04/14/2020 regarding the 02/11/2020 communicable disease diagnosis that R1 acquired during R1’s stay at the facility. The interview revealed that the disease could only have been acquired through a contact with another person within 10 to 90 days from the date of contact.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20200213125706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GLEN PARK AT VALLEY VILLAGE
FACILITY NUMBER: 197603165
VISIT DATE: 02/04/2021
NARRATIVE
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(continued from LIC 9099-C)

The only time within that period that R1 was not at the facility was on 01/28/2020 when R1 had a medical appointment accompanied by a family friend. Investigator Seng interview with the family friend revealed that the family friend picked up R1 at around 9:00 AM for the 10:00 AM appointment and went straight back to the facility after the appointment. Investigator Seng interviewed the staff at the medical center where R1 had an appointment and confirmed that R1 was with the family friend during and all throughout the appointment.

Investigator Seng obtained and reviewed a written declaration 12/13/2020 from a medical expert on communicable disease who studied the case extensively, and concluded with reasonable medical certainty that R1 had indeed acquired the communicable disease with contact from another person within two (2) to four (4) weeks from the date it was found (02/11/2020), which would place the resident in the facility’s care.

Based on information gathered during the course of the investigation, the allegation is deemed substantiated. Deficiency and civil penalty assessed for a violation that resulted in an injury or illness to a resident in care.

The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(e)

Appeal rights discussed and given.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Citations on this Visit Report are Under Appeal!

Control Number 31-AS-20200213125706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE
FACILITY NUMBER: 197603165
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/08/2021
Section Cited
CCR
87468.1(a)(2)
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To be accorded safe, healthful and comfortable accommodations, furnishings and equipment

This requirement is not met as evidenced by:

Based on IB investigation, the facility failed to ensure that health and safety of R1 resulting
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The Licensee/administrator shall submit a written plan, including proof of vendorized staff training, on how the Licensee will ensure that resident’s personal rights are regularly observed, and that appropriate care is provided to residents. Written POC to be submitted to CCL on or before the POC date.
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to R1 contracting communicable disease while in the care of the facility. This poses an immediate health and safety risk to the 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: Jill NakataTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Kelly BurleyTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20200213125706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE
FACILITY NUMBER: 197603165
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/06/2021
Section Cited
CCR
87464(f)(1)(2)&(4)
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(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). (2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations Services (4) Personal assistance and care as needed
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The Licensee/administrator shall submit a written plan, including proof of vendorized staff training, on how the Licensee will ensure that resident’s physical and mental condition are regularly observed, and that appropriate care is provided to residents. Written POC to be submitted CCL on or
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by the resident as indicated in the pre-admission appraisal...This requirement is not met as evidenced by: Based on investigation, the facility failed to ensure that R1 was properly provided care and supervision resulting to R1 contracting communicable (continued to right)
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before the POC date. Licensee/administrator will submit scheduled training information and submit proof of training after completion.

disease while in the facility. This poses an immediate health and safety risk to the 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: Jill NakataTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Kelly BurleyTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5