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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 08:03:01 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
02/18/2020 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20200218121919
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:
02:33 PM
MET WITH:Tillman Pink III - AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident sustained pressure injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit with 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 02/18/2020, 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 Investigator Dennis Seng.

On 02/20/2020 at 9:45 AM, 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-20200218121919
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)

The complainants concern is that Resident #1 (R1) sustained pressure injuries while in care.

IB Investigator Dennis Seng conducted interviews with facility staff on 03/04/2020. Staff interviewed were the primary care staff prior to R1’s hospitalization. The interview revealed that Staff #1 (S1) questioned R1 and physically conducted body checks only when R1 felt pain anywhere on the body. Staff #2 (S2) indicated that regular body checks were conducted on R1, however, when asked, could not recall how the body checks were performed.

Medical Records were subpoenaed on 02/24/2020 and received by the department on 03/11/2020. LPA reviewed hospital records on 01/30/2021. Medical records revealed that the R1 was noted to have pressure sore wound on admission (02/11/20) by the nurse. Wound Care Specialist nurse evaluated the pressure injury (pressure sore) of R1 on 02/12/2020 and stated that R1 had Pressure Injury upon admission on 02/11/2020 and staged the right shoulder (Pressure Sore Injury stage II) and sacrum (Pressure Sore Injury stage III).

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: 2 of 5
Control Number 31-AS-20200218121919
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
87464(f)(1)(4)&(5)
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(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). (4) Personal assistance and care as needed by the resident as indicated in the pre-admission appraisal...(5) Regular observation of the resident's physical and mental condition
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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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as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by: Based on IB investigation, the facility failed to ensure that R1 was properly provided care and supervision resulting to R1 sustaining pressure injury while in the facility, which poses (see right)
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before the POC date. Licensee/administrator will submit scheduled training information and submit proof of training after completion.

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: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/18/2020 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20200218121919

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:
02:33 PM
MET WITH:Tillman Pink III - AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility has scabies

Insufficient staffing to meet resident's needs
INVESTIGATION FINDINGS:
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This is an amended report to add the allegation above, there is no change in the finding.

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit with Tillman Pink III to deliver the findings for the above allegations. 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 02/18/2020, 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 Investigator Dennis Seng. On 02/20/2020 at 9:45 AM, LPA Manya Lefian, initiated the complaint visit. LPA interviewed facility staff and obtained copies of the facility records.

(continued on LIC 9099-C)
Unsubstantiated
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: 4 of 5
Control Number 31-AS-20200218121919
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-A)

Regarding the allegation that the facilities has scabies, LPA record review revealed that the facility had scabies outbreak but this was reported to Los Angeles County Department of Health (LACDPH) who provided guidance to the facility to address the outbreak and eventually was cleared by the LACDPH on July 2019. While the facility continued to have small outbreaks, LPA interview with former administrator revealed that the former administrator trained staff to care for those residents with scabies per the Center for Disease Control (CDC) guidelines and put the protocol in place in accordance with LACDPH and CDC guideline.

Regarding the allegation that the facility has insufficient staffing to meet the residents’ needs, IB Investigator Seng’s interview with care staff revealed that R1 would like to shower on R1’s own and would get upset if care staff assist R1 during shower but would remain on stand by while R1 is taking shower. Moreover, all three (3) care staff interviewed also revealed that R1 could change own diaper and the staff offered to assist but was refused by R1. LPA record review revealed that the facility has four (4) care staff during morning shift (6:00 AM to 3:30 PM) with two (2) staff on rotational duty that could assist with care if needed and three (3) care staff during afternoon shift (2:30 PM to 11:00 PM) with one (1) to two (2) additional staff on rotational duty that could assist with care if needed.

Based on the information gathered during the course of the investigation, the allegations above are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this 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: 5 of 5