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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 09/29/2023
Date Signed: 09/29/2023 02:38:11 PM

Document Has Been Signed on 09/29/2023 02:38 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 VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:TILLMAN PINKFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 100TOTAL ENROLLED CHILDREN: 0CENSUS: 44DATE:
09/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Molly AyalaTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management-Deficiencies visit due to deficiencies observed during the course of the audit investigation for C#29-AS-20210310091929. LPA Urena and Jessica Chen, General Auditor III (joined via Microsoft Teams) met with facility representative Molly Aayala, and explained the reason for the visit.

During the course of the audit investigation for complaint C#29-AS-20220826155207, the Department’s Audit Section concluded the following three deficiencies:

Deficiency #1: Safeguards for Resident Cash, Personal Property, and Valuables
The audit review revealed the following -The facility’s cash handling policy and procedures describe that residents sign for their deposits and withdrawal on the ledgers (LIC 405). However, residents’ signature/initials were not found on the ledgers, only the accounting personnel typed initials were recorded on the ledgers. Residents are given a “petty cash slip” to sign when the residents receive cash. The “petty cash slip” is the only place a signature from the resident is obtained, which includes the business manager/staff initials/signature on the slip as facility representative. This system does not allow for the resident to acknowledge their balance including deposits and withdrawal amounts. Residents should be able to see their ledger amounts to ensure they are free of error and deposits are entered in a timely manner. Residents were asked to sign the individual “petty cash slips” which would not allow for the resident to be aware of the total amount they have and how much is credited each month. A LIC 405 ledger was maintained for each resident the facility handles cash for, however, the LIC 405 forms submitted for audit review appear to be entered by the accounting personnel at the corporate office, with accounting personnel initials typed in, and not at the facility.No residents’ signatures were observed on the LIC 405 ledgers, which is inconsistent with their policies and procedures.
Continues on LIC 809C-page 2.
Kasandra LopezTELEPHONE: (818) 596-4343
Sandra UrenaTELEPHONE: 747-230-3919
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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: 09/29/2023
NARRATIVE
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The licensee failed to maintain adequate safeguards and accurate records of cash resources and valuables entrusted to their care, including, but not limited to the following: (1) Records of residents' cash resources maintained as a drawing account shall include a ledger accounting (columns for income, disbursements, and balance) for each resident, and supporting receipts filed in chronological order.

Deficiency #2: Surety Bond – Insufficient Coverage
The audit review revealed the following -The auditor requested the surety bond from the licensee. The review of the surety bond revealed that the current coverage is for $11,000 thousand. No expiration date was shown on the certificate. Auditor made inquiry to the bond issuer if the bond was still valid and for the expiration date. The bond issuer responded that the surety bond is still valid until it’s next renewal date of 12/4/2023. However, audit review of the residents’ trust accounts noted that the facility normally safeguards between $44,000 to $53,000 per month. The amount of the surety bond shall be according to the following schedule: Amount safeguarded per month $1,501 to $2,500, bond required $3,000. Every further increment of $1,000 or fraction thereof shall be required to have an additional $1,000 on the bond.”

The facility failed to maintain sufficient surety bond coverage to safeguard the residents’ resources. The current $11,000 surety bond coverage is not sufficient and needs to be increased for the amount that is being safeguarded.
Deficiency #3: Some residents’ P&I were mishandled, due to lack of supporting documents for cash withdrawals, purchases, other deductions, and rent miscalculation.
The audit review revealed the following- Based on documentation and information reviewed by the auditor, the facility handles cash resources for 16 residents, including 3 residents that the facility is the SSI representative payee.
Admission Agreements, LIC 602 (Physician Report), financial ledger LIC 405 forms, “petty cash slips” and purchase invoices were requested and reviewed for the residents. Some cash withdrawals and purchases were not accepted for audit due to lack of supporting documentation. Instances noted, “petty cash slip” had no residents’ signature; invoiced amount disagrees with the recorded purchased amount; the “petty cash slip” were from dates out of the audit period.
Continues on LIC 809C-page 3.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
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: 09/29/2023
NARRATIVE
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During the audit, the residents’ LIC 602 were reviewed, and it revealed that some residents are not able to leave the facility unassisted; are not even able to transfer to and from bed or have dementia. Although these residents do not leave the facility, there were frequent, and material amounts of cash withdrawals recorded on their ledgers and the petty cash slips. The auditor provided the facility the draft of audit working papers, listing questionable transactions, by resident. Auditor made inquiry regarding where, how, when, and who accompanied these residents to spend the cash. The facility did not provide an explanation or supporting documents. The withdrawals are not supported, and the facility is to refund the residents accordingly. The documentation submitted and reviewed disclosed that the facility mishandled some of the residents’ funds.

The following amounts show the refund amount determined for each resident:
R1-$424; R2-$60; R3-$270; R4-$253; R5-$1,055; R6-$290; R7-$502; R8-$20; R9-$0; R10-$910; R11-$438; R12-$760; R13-$130; R14-$1,678; R15-$1,584; R16-$664.
TOTAL Refund for 16 residents: $9,038.00.

Based on records review and the information obtained, the following deficiencies were observed. Pursuant to Title 22 of the CA Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 809-D)

Citations were issued. Exit interview conducted with facility's representative. Today's reports, and appeal rights were reviewed, and issued.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/29/2023 02:38 PM - It Cannot Be Edited

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: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/16/2023
Section Cited
CCR
87217(g)(1)

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87217 (g)(1) Safeguards for Resident Cash, Personal Property, and Valuables. Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, including, but not limited to the following...the resident's signature or mark, or responsible party's full signature...This requirement was not met.
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Effective immeadiatly as 09/29/2023: Licensee must maintain a current and accurate account of resident's cash resource by using a ledger (LIC405) for each resident with income, disbursement, and balance with date of transaction, description and signature of the resident and the office representative involved with the transaction. The “petty cash” slips used need to be replaced with a “cash receipt”.
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Based on record review, no residents’ signatures were observed on the LIC 405 ledgers, which is inconsistent with the facility's policies and procedures. The licensee failed to maintain adequate safeguards and accurate records of cash resources and valuables entrusted to their care, which poses a potential health and safety danger to persons in care.
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Type B
10/16/2023
Section Cited
CCR87216(1)

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Section 87216 (1) Bonding- Each licensee, other..., shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. The amount of the bond shall be in accordance with the …schedule. This reuirement was not met.
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Licensee will submit proof of the amount increase of surety bond per the set schedule to CCLD office by 10/16/2023.


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Based on record review, the facility failed to maintain sufficient surety bond coverage to safeguard the residents’ resources. The current $11,000 surety bond coverage is not sufficient and needs to be increased for the amount that is being safeguarded. which poses a potential health and safety danger to persons 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.
Kasandra LopezTELEPHONE: (818) 596-4343
Sandra UrenaTELEPHONE: 747-230-3919

DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023

LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 09/29/2023 02:38 PM - It Cannot Be Edited

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: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/16/2023
Section Cited
CCR
387217(c)(1)

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387217 (c) (1) Safeguards for Resident Cash, Personal Property, and Valuables-Every facility shall account for any cash resources entrusted to the care or control of the licensee or facility staff, (1) Cash resources include … and personal and incidental need allowances from funding sources such as SSI/SSP. This requirement was not met.

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 Licensee is to refund the residents’ accounts for the amount as listed for each of the sixteen (16) residents. Proof of the refund (copies of cashed checks by residents) must be submitted to the CCLD office by 10/16/2023.
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Based on record review, the withdrawals are not supported, and the facility is to refund the residents accordingly. The documentation submitted and reviewed disclosed that the facility mishandled some of the residents’ funds.
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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.
Kasandra LopezTELEPHONE: (818) 596-4343
Sandra UrenaTELEPHONE: 747-230-3919

DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023

LIC809 (FAS) - (06/04)
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