197609005-7-21-2020-28-AS-MVAO-BXPMTB-20210128085317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 07/17/2020
Date Signed: 07/21/2020 12:22:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2020 and conducted by Evaluator Renee Arterberry

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200717092309

FACILITY NAME:	GLEN TERRA ASSISTED LIVING		FACILITY NUMBER:	197609005
ADMINISTRATOR:	RECORDS, TERRY		FACILITY TYPE:	740
ADDRESS:	917 N LOUISE STREET		TELEPHONE:	(818) 291-1918
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91207
CAPACITY:	155	CENSUS: 85	DATE:	07/17/2020
		UNANNOUNCED	TIME BEGAN:	02:14 PM
MET WITH:	Carlos Lara, administrator		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Resident has had multiple falls while in care due to staff neglect
Staff is not allowing resident to accept calls

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ren'ee Arterberry initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was virtually conducted telephonically with Administrator Carlos Lara.
The investigation consisted of the following; prior to the visit the LPA contacted the complainant and conducted a telephone interview regarding the allegations noted above. The LPA interviewed the facility administrator at 2:20 PM and an individual who shall be referred to as, M1 at 2:30 PM. The LPA also interviewed a resident who shall be referred to as, R1 at 2:45 PM. Two other residents who are assigned the bedrooms in the same location as R1 and they shall be referred to as, R2 and R3. In addition, three caregivers were randomly selected (using the Personnel Roster) who shall be referred to as, S1, S2 and S3 were also interviewed at 3:05 PM. The LPA requested and was supplied copies of the following documents: Glen Terra Assisted Living Personnel Roster and Physician's Report for R1. The investigation reveal the following: Resident has had multiple falls while in care due to staff neglect: the administrator state that although R1 has an unsteady gait, she does not have a history of falls.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee Arterberry	TELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020

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 28-AS-20200717092309

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN TERRA ASSISTED LIVING	FACILITY NUMBER: 197609005
	VISIT DATE: 07/17/2020

NARRATIVE

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R1 state that she fell in January 2020, once but deny that she have a history of falls. R1 alerted a caregiver and she was very helpful. The caregivers check on her though out the day and deny that she have fallen multiple times. The caregivers state that R1 have an unsteady gait but deny that they witnessed or was told that R1 have fallen multiple times. The caregivers also state that they often check on R1 and all the residents. M1 state that he communicate with R1 daily and she told him she fell once during the early part of the year and no other falls have been reported to him by R1. M1 also state that R1 have not reported to him that the caregivers do not check on her or fail to provide assistance to her. R2 and R3 have no knowledge that R1 fell or that she required assistance that the caregivers failed to provide. Staff is not allowing resident to accept calls: The administrator state that R1 have not requested to use the facility phone. The phone calls for R1 do not come through the facility office because there is a phone in her bedroom. R1 state that she have not requested to use the facility phone because she have a cellphone and there is also a phone (land line) in her bed room. M1 state that R1 have a cellphone and do not request to use the facility phone. M1 deny directing/routing the calls for R1 to his personal cellphone. R2 and R3 state that they have cellphones, there are also phones in their bedrooms. The facility staff do not interfere or prohibit them from placing or accepting phone calls. It is noted on the Physician's Report that R1 is ambulatory. It is not noted on the Physicians' Report for R1, that she is not a fall risk or have a history of falls. The administrator, three caregivers, M1, R1 and two residents were interviewed. The facility file for R1 was reviewed. R1 state that she fell once and deny that she fell multiple times. The administrator state that he was aware that R1 fell, once. The caregivers, M1 and R2 and R3 deny witnessing or being told that R1 fell multiple times.

There is no evidence to support that R1 fell multiple times. R1 state that she have a cellphone and a phone in her bedroom. R1 deny that the facility staff are prohibiting or restricting phone calls to or from her. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the complaint investigation of the allegations; resident has had multiple falls while in care due to staff neglect and staff is not allowing resident to accept calls the finding based on the evidence; interviewed conducted and documents provided is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. A telephonic exit interview was conducted, and a hard copy will be provided with signature via email.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee Arterberry	TELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020

LIC9099 (FAS) - (06/04)

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