197609005-10-5-2021-28-AS-FFIS-C8MR5E-20211110114300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 10/05/2021
Date Signed: 10/05/2021 11:17:00 AM

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
08/06/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20210806114742

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: 87	DATE:	10/05/2021
		UNANNOUNCED	TIME BEGAN:	10:09 AM
MET WITH:	Carlos Lara - Administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident's colostomy bag is not being regularly changed

INVESTIGATION FINDINGS:

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This report supersedes report created on 8/10/21 to correct resident #1 to resident #4 and residents' interview finding. On 8/10/21 Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation regarding the above allegation. LPA Flores met with Jessica Almendarez receptionist and explained the reason for the visit. Administrator Carlos Lara arrived an hour later.

The investigation consisted of the following: LPA Flores requested staff/resident roster, interviewed executive director, wellness director, staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5), and residents #1(R1),#2(R2), #3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8), reviewed residents files and requested copies of needs and care plan, physician's report, and care notes for all 8 residents.

The investigation revealed the following: Regarding allegation: Resident's colostomy bag is not being regularly changed. It is alleged facility doesn't change resident's colostomy bags timely and bag had not been changed in 14 hours and was starting to leak. (CONTINUED LIC 9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

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-20210806114742

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: 10/05/2021

NARRATIVE

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During interviews with residents 2 out of 8 residents stated to not need assistance from nurse at the facility and are independent and have observed others obtained assistance right away. 3 out of 8 residents stated that wellness team has responded right away or in a considerate amount of time to residents' needs. 2 out out of 8 residents stated it could take the wellness team up to 30 minutes to 90 minutes to provide assistance, and 1 out of 8 residents interviewed stated that wellness team does not respond when assistance is needed. During interviews with staff 3 out of 5 staff stated residents with colostomy bag are changed as needed or at least twice a day. 1 out of 5 staff stated residents with colostomy bag are change every other day, and 1 out of 5 staff stated not to know how often the colostomy bag is changed. Wellness director stated that home health care is assigned to residents with colostomy bag to assist during wellness director's days off, and administrator stated that facility's policy for the wellness director to check on residents with colostomy bags upon arriving to the facility and before leaving the facility, and it may be change as needed per residents' request, and facility is responsible for that care. LPA reviewed residents' documents and it was revealed R4 needs assistance with changing colostomy bag. R4's physician's report states the following "colostomy bag - needs bag changed every 4 days or sooner PRN". Although R4 may request assistance with colostomy bag more often, the documentation reviewed and interviews conducted supports the facility is providing R4 with assistance per physician written orders and resident's request.

Based on LPA's observations, interviews and documents reviewed the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED.

Exit interview was conducted with Carlos Lara and a copy of the report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

LIC9099 (FAS) - (06/04)

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