197609005-12-1-2021-28-AS-FFIS-C9T8AW-20211217212125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 12/01/2021
Date Signed: 12/01/2021 11:46:32 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
11/24/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211124164511

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: 94	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Carlos Lara; Executive Director		TIME COMPLETED:	12:03 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident smoking at the facility where oxygen is in use.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit to investigate the above allegation. LPA met with Administrator Carlos Lara and explained the reason of the visit.

The investigation consisted of the following: LPA obtained copies of Resident & Staff Rosters, Admission Agreement, House Rules, Physicians Report and Resident Appraisal for Resident #1. LPA interviewed Staff #1 - Staff #5 and Resident #1 - Resident #9. LPA also toured the facility which included the common areas and random sample of resident rooms.

The investigation revealed the following: in regards to the allegation "resident smoking at the facility where oxygen is in use", it is alleged that there are residents in the 2nd floor of the facility that are smoking in their rooms. Interview conducted with Administrator revealed that residents are not allowed to smoke in their rooms. There is a designated smoking area in the facility which is located in the front of the facility.

(CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20211124164511

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: 12/01/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Administrator indicated that R1 recently moved into the facility on 11/01/21 and it has been brought up to his attention that R1 will smoke in his room. Administrator has spoken to resident about not smoking in his room. There are no oxygen tanks in R1's room. LPA reviewed Facility House Rules which states "no smoking is allowed in apartments" and "smoking is permitted in the designated area only". Administrator indicated he is trying to work with R1 as he is a new resident, however he has told the resident that smoking in the room will not be allowed. 8 out 9 residents interviewed indicated that they do not smoke in their rooms and they have not observed any other residents smoking in their rooms. All residents interviewed indicated that they are aware of the smoking area located in the front of the facility. 5 out of 5 staff members interviewed indicated that residents are not allowed to smoke in their rooms however some residents do. Staff members interviewed indicated that they will tell residents not to smoke in their rooms and will notify management when they observe it. Staff members interviewed indicated will assist residents to the smoking area if needed. LPA toured and observed the designated smoking area. LPA toured a random sample of resident rooms and did not observe any residents smoking in their rooms or smell any smoke in the hallways of the facility during the tour. Although it was verified that R1 has smoked in his room, facility is actively taking appropriate steps to address the situation with the resident. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2