197609005-3-4-2021-28-AS-MVAO-C5AT8M-20210726143034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 03/03/2021
Date Signed: 03/04/2021 05:59:06 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
01/11/2021 and conducted by Evaluator Christine Wong

COMPLAINT CONTROL NUMBER: 28-AS-20210111105920

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: 82	DATE:	03/03/2021
		UNANNOUNCED	TIME BEGAN:	10:59 AM
MET WITH:	Carlos Lara		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility did not meet resident's need for care and supervision.
Facility did not ensure that resident's oxygen equipment was operable.
Facility does not have an emergency disaster plan for power outages.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong initiated a subsequent complaint investigation to deliver findings on the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Executive Director Carlos Lara

The investigation consisted of the following: On 01/15/21, an initial 10-day complaint visit was conducted by LPA. A virtual physical plant inspection of the facility was conducted via FaceTime between 2:38pm to 2:53pm with Executive Director Carlos Lara and maintenance person Samuel Adzhemyan. LPA observed the standby generator located outside the facility, emergency light at all public bathrooms, laundry room, stairway and hallway. LPA also interviewed executive director and LPA requested documents including residents rosters, staff rosters with phone #, facility emergency disaster plan, Resident#1 (R1)'s face sheet and recent physician report. LPA also interviewed eight (8) residents on 02/05/21 and four additional staff on 02/11/21 and 02/17/21.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

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 28-AS-20210111105920

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: 03/03/2021

NARRATIVE

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The investigation revealed of the following: Allegation#1 “Facility did not meet resident’s need for care and supervision.” LPA interviewed residents and they all reported the facility can meet their needs and the facility takes good care of them. Staff all reported that they would try their best to meet residents’ needs and ensure them all receive adequate care and supervision in the facility.

Allegation#2 “Facility did not ensure resident’s oxygen equipment was operable. LPA interviewed residents and all reported the staff came in the room and checked on the residents while facility had power outage and it only lasted for less than 10 minutes. Staff also reported they checked each resident in the facility. Besides that, they also checked residents who has electrical bed or oxygen machine in the room and ensure the residents were doing okay and the machines are operable. Staff stated all residents are doing fine while the power was off.

Allegation#3 “Facility do not have an emergency disaster plan for power outages. During the investigation, LPA observed there’s a standby generator located outside the facility and emergency light at all public bathrooms, laundry room, stairway and hallway and they were all operable. LPA also reviewed the facility emergency disaster plan for power outages, and they do have an updated emergency disaster plan in place for the facility. For electricity, they do have a separate electrical room across from the trash bins. Administrator also reported if there’s any power outage or emergency, the on-duty staff would go to each room and ensure each resident are doing fine and safe in the facility.
Based on statements and interviews conducted with staff and residents’ families, review of facility documents and LPA’s observation and there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore all the allegations are UNSUBSTANTIATED.

A telephonic exit interview was conducted with Executive Director Carlos Lara. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 and LIC 9099C reports and return to LPA.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

LIC9099 (FAS) - (06/04)

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