197603165-11-15-2024-29-AS-KHEN-DBD3BA-20241125170601

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 11/15/2024
Date Signed: 11/15/2024 06:58:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
02/27/2023 and conducted by Evaluator Christine Yee

COMPLAINT CONTROL NUMBER: 29-AS-20230227151830

FACILITY NAME:	GLEN PARK AT VALLEY VILLAGE		FACILITY NUMBER:	197603165
ADMINISTRATOR:	TILLMAN PINK		FACILITY TYPE:	740
ADDRESS:	5527 LAUREL CANYON BLVD		TELEPHONE:	(818) 769-6626
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	100	CENSUS: 43	DATE:	11/15/2024
		UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	David Aguiniga, Executive Director		TIME COMPLETED:	07:00 PM

ALLEGATION(S):

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1. Resident sustained pressure injuries while in care
2. Staff do not meet resident's incontinence needs
3. Administrator is not at the facility sufficient hours to permit adequate attention to management
4. Staff do not assist resident with grooming
5. Staff do not follow infection control protocol
6. Staff do not report incidents to appropriate parties
7. Staff do not communicate with responsible party regarding resident's care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Yee conducted a subsequent unannounced complaint visit to continue investigation into the above allegations and initially met with Virginia Sumulong, Assistant Administrator. The Executive Director arrived at 12:09pm to participate in the visit. The reason for today's visit was explained.

On 3/2/23 Angel Ascencio conducted an initial 10-day visit. LPA met with Executive Director Tillman Pink at 10:23 a.m. and explained the reason for visit. During the initial visit, LPA Ascensio reviewed resident files at 10:30 a.m., conducted resident interviews starting at 11:11 a.m., and recieved pertinent documents. LPA determined that further investigation is needed. LPA will return at a later time to conclude the investigation.
Staff member was authorized to sign documents. Exit interview conducted and a copy of the report was issued to Executive Director.

continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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 4

Control Number 29-AS-20230227151830

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/15/2024

NARRATIVE

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On today's visit LPA Yee conducted additional interviews. LPA conducted interviews with Virginia Sumulong, Assistant Administrator at 11:50am, Staff #1 at 12:37pm and the Executive Director at 3:36pm and reviewed and obtained additional facility files throughout the visit.

Per information received regarding Allegation #1 - Resident sustained pressure injuries while in care, the investigation revealed that the resident was observed with a open wound on their coccyx on 11/28/22 and a scar between the buttocks. The wound was cleaned, treated with incontinence cream, resident was re-positioned to take pressure of the wound and a home health referral was requested. Per review of hospice records, Resident #1 was receiving wound care and the nurse notes "in addition to poor circulation, neuropathy and difficulty moving, factors that contribute to chronic wounds include systemic illness, age and repeated trauma. Patient was instructed on factors that may contribute to chronic wounds is old age. The skin of older people is more easily damaged, and older cells do not proliferate as fast and may not have an adequate response to stress in terms of gene up regulation of stress related proteins." Incontinence may have been a contributing factor but there is no conclusive evidence that it was sole reason for the cause of the pressure injury. The report does not indicate that the wound was the result of neglect on the part of facility staff. Staff interviewed deny that residents are left unattended for long periods of time in their soaked diapers. This may or may not have happened, but there is no preponderance of evidence to conclusively say it was neglect on the part of the staff's failure to timely change the resident. Therefore, allegation is UNSUBSTANTIATED at this time.

Investigation into Allegation #2 - Staff do not meet resident's incontinence needs, per Staff interviewed, incontinent residents are checked every 2 hours or 1 hour if they are observed to get wet more frequently or when they pull the signalling system. The signalling system is monitored in the front office and staff is sent to change the resident. There are 3 caregivers on schedule for the first two shift and 2 on the night. If one caregiver is helping a resident, the next available staff will handle the call. Per staff interviewed, if someone calls out and there is not staff available to do overtime, they use agency staff. Per the investigation, it may or may not have happened, but there was no preponderance of evidence to support the allegation that the staff do not meet the residents' incontinence needs therefore, the allegation is UNSUBSTANTIATED at this time.

continued on LIC9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230227151830

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/15/2024

NARRATIVE

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Regarding Allegation #3 - Administrator is not at the facility sufficient hours to permit adequate attention to management, per interviews conducted with Staff #1, a long time employee since 2016, Tillman Pink III, Administrator was in the office daily. His regular hours were from 9am - 5:30pm. However, he would be in the office for a couple hours or longer and would leave, sometimes to do resident assessments or for other reasons. When he was in the facility, he would have his office doors closed the whole time so people would not know he was at the facility. When he was in the office of away from the office, Janice Pink, Assistant Administrator was in the facility and she provided management needs. She was in the office, Monday through Friday from 9am - 5:30pm. Based on information received, the facility may have or may not have had adequate management attention, there was no preponderance of evidence to conclusively support the allegation that the Administrator is not at the facility sufficient hours to permit adequate attention to management. Therefore, the allegation is UNSUBSTANTIATED at this time.

Per investigation into Allegation #4 - Staff do not assist resident with grooming, interviews with staff indicated that they give residents their baths on a schedule. The residents get baths 2 times a week. Once the residents are given their baths, the staff complete the shower log for the date that the shower was provided. If the resident refuses to shower, the reason is noted on the resident's shower log. Per review of Resident #1's Internal Incident Report for February 2023, Resident #1 refused to shower even after multiple attempts.
Per information received during the investigation, there was insufficient evidence to support the allegation that the staff do not assist the resident with grooming as the resident has the right to refuse service or assistance with care. Therefore, the allegation is UNSUBSTANTIATED at this time.

Per investigation in Allegation #5 - Staff do not follow infection control protocol - per the reporting party, the facility does not have gloves, masks, wipes readily available for staff use. The investigation revealed that the facility has plenty of PPE's. They have gloves, surgical mask, N95s, wipes and gowns. They do provide staff with especially gloves to do their job. Based on the information provided, there was insufficient evidence to support the allegation the staff do not follow infection control protocol. PPE may or may not have been used by staff but there is no preponderance of evidence to support the claim that staff do not follow infection control protocol at this time. Therefore, the allegation is UNSUBSTANTIATED at this time.

Investigation into allegation #6 - Staff do not report incidents to appropriate parties, complainant was told by an unknown someone, who may or may not be a reliable source that the facility is not reporting incidents to

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20230227151830

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/15/2024

NARRATIVE

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the appropriate parties. Without the specific details of the incidents being referred to LPA Yee was not able to verify if those incidents did or did not occur or when they occurred. The complainant refers to a fall sustained by Resident #1 on 11/12/23 but no further details were provided. Was Resident #1's fall witnessed by staff and which staff observed the fall and was the staff made aware of the fall. One specific incident that was referred to was that the facility had a Covid-19 outbreak in December 2022, LPA Yee was able to verify with Department records that the facility did report the outbreak to the Department on 12/29/22. Without further information, there is insufficient evidence to support the allegation that Staff do not report incidents to appropriate parties, therefore the allegation is UNSUBSTANTIATED at this time.

Investigation into Allegation #7 - Staff do not communicate with responsible party regarding resident's care, LPA Yee was unable to verify if attempts were made with the previous Administrator to discuss Resident #1's care as the previous Administrator is no longer employed at the facility. At the time that this complaint was received, the facility also had a Assistant Administrator that the reporting party could have communicated with. Failure to reach the Administrator to discuss the resident's care should not have prevented the reporting party from communicating with other facility staff regarding Resident #1's care. Based on the investigation, there is insufficient evidence to support the allegation that staff do not communicate with responsible party regarding resident's care therefore the allegation is UNSUBSTANTIATED at this time.

No deficiencies cited on today's visit.

Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

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