197603165-10-19-2021-31-AS-DPEA-C88MQU-20211028094919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 10/19/2021
Date Signed: 10/19/2021 04:03:27 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
03/23/2020 and conducted by Evaluator Martha Guzman-Chavez

COMPLAINT CONTROL NUMBER: 31-AS-20200323095639

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:	03:11 PM
MET WITH:	Elizabeth Torres - Assistant Administrator		TIME COMPLETED:	04:02 PM

ALLEGATION(S):

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Facility staff failed to provide resident's records to resident's authorized representative – Substantiated

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 conclude an investigation initiated by LPA Heffernan on 04/01/2020. 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 04/01/2020, LPA Heffernan conducted a telephonic interview with Administrator, Rafael Silva between 9:18am and 9:42am. LPA Heffernan also requested copies of the medical records and a written statement from the facility’s attorney advising the facility what to do regarding the request for records. On 10/12/2021, LPA Guzman Chavez conducted a subsequent visit to the facility and interviewed current Administrator Tillman Pink at 3:30pm. Additional pertinent documentation was obtained and reviewed during the course of the investigation.
(...Continued on LIC 9099C...)

Substantiated

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 31-AS-20200323095639

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...)

It was alleged that on 03/20/2020, “Facility staff failed to provide resident's records to resident's authorized representative.” It was reported that on 03/23/2020, a Letter to Preserve Evidence was sent Glen Park at Valley Village by the attorney representing the Power of Attorney (POA) of a resident. Additionally, a request for Medical Records was also sent to the Custodian of Records at Glen Park at Valley Village on 03/02/2020.

Interviews conducted revealed that documents were not released to the requesting party within the time allotted by regulations. Furthermore, interviews and documentation reviewed revealed, that that documents were held from POA per facility attorney stating, “Glen Park is not allowed to legally provide copies of any residents file without documented permission to ‘Release Medical Information’ signed by the Resident/Residents Power of Attorney.” However, records reviewed revealed that the representing attorney of the POA submitted all necessary documents along with request. Based on interviews and documents obtained, the allegation “Facility staff failed to provide resident's records to resident's authorized representative” is deemed substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D)

Exit interview conducted, citations issued, appeal rights discussed, and a copy of this 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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Control Number 31-AS-20200323095639

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/29/2021 Section Cited CCR 87468.2(19)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities. (19) To have prompt access to review all of their records and... photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee has agreed to do the following: 1. Third party training and acknowledgment in Title 22, Division 6, Chapter 8. 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities by 10/29/2021.
	8 9 10 11 12 13 14	Based on interviews, and record review, the licensee did not meet the above section by failing to produce requested records resulting in a potential risk to the personal rights of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

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