197603165-10-19-2021-29-AS-DPEA-C89P2A-20211029105538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 10/19/2021
Date Signed: 10/19/2021 03:10:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/15/2020 and conducted by Evaluator Martha Guzman-Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20200615143142

FACILITY NAME:	GLEN PARK AT VALLEY VILLAGE		FACILITY NUMBER:	197603165
ADMINISTRATOR:	PINK, JR, TILLMAN		FACILITY TYPE:	740
ADDRESS:	5527 LAUREL CANYON BLVD		TELEPHONE:	(818) 769-6626
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	100	CENSUS: 34	DATE:	10/19/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Elizabeth Torres - Assistant Administrator		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff hit resident while in care - Unsubstantiated
Resident is not afforded privacy while in care – Unsubstantiated

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 06/22/2020 by LPA Brian Balisi and a subsequent visit was conducted on 08/09/2021 by LPA Guzman Chavez. On today’s visit, LPA Guzman Chavez met with Assistant Administrator Elizabeth Torres as Administrator Tillman Pink III was unavailable in a meeting. Entrance interview was conducted.

During the initial visit on 06/22/2020, LPA Balisi conducted a telephonic interview with Administrator, Rafael Silva between 1:45pm and 2:45pm. On 08/09/2021, LPA Guzman Chavez conducted a physical plant tour with Assistant Administrator, Elizabeth Torres at 2:50pm and conducted four resident interviews between 3:00pm and 4:15pm. On 10/12/2021, LPA conducted five staff interviews between 2:07pm to 2:42pm, seven resident interviews between 2:44pm and 3:25pm, and then interviewed Administrator, Tillman Pink III at 4:15pm.
(...Continued on LIC 9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200615143142

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE	FACILITY NUMBER: 197603165
	VISIT DATE: 10/19/2021

NARRATIVE

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(...Continued from LIC 9099...)

During the course of the investigation, LPA was unable to determine R2’s identity through staff and resident interviews. Also, R1 no longer resides at the facility and S1 no longer works at this facility, both were unreachable for interviewing. Additionally, LPA Guzman Chavez conducted interviews with North Los Angeles County Regional Center (NLACRC) on 08/30/2021 at 11:24am. Pertinent documentation was also obtained and reviewed during the course of the investigation.

It was alleged that on 04/28/2020, staff hit a resident while in care. It was reported that on 04/28/2020, at approximately 4:30am, there was an incident that occurred between Resident #1 (R1) and Resident #2 (R2) at the facility. Staff #1 (S1) intervened as R1 went into the other residents’ room and started to record the two residents. R1 became upset at S1 and slapped S1 who in return slapped R1.

Interview with the Administrator revealed that on 04/28/2020, there had been no physical altercation, however, there was a verbal altercation between R1 and S1. Interview with NLACRC representative revealed that there was no incident report submitted regarding alleged incident involving R1 and S1. Additionally, interviews with residents revealed that they have not witnessed any facility staff become physical with any resident. Nor have they heard another resident complain about being mistreated by staff. Based on interviews and documentation gathered, it has been determined that the Department does not have sufficient information to determine that the staff hit the resident; therefore, the allegation “staff hit resident while in care” is deemed Unsubstantiated at this time.

It was further alleged that residents are not afforded privacy while in care due to staff coming into residents’ room without notifying the residents and recording the residents. Interviews with residents revealed that they are able to lock their doors at any time and staff knocks on the resident’s door before entering at any time. Furthermore, staff only come into residents’ room when they are conducting wellness checks throughout the facility or when doing housekeeping. When asked if they felt they had enough privacy while in their rooms, interviews with residents revealed that they feel they have privacy while in their rooms and, no one has ever recorded them without their consent. Interviews with staff revealed that the protocol for entering a resident’s bedroom at any time is knocking first, wait for a few seconds for a response, and then walk in. Based on interviews and the information obtained, it has been determined that the Department does not have sufficient information to determine residents are not afforded privacy. Therefore, the above allegation “Resident is not afforded privacy while in care” is deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued. Copy of report sent via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

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