197609005-11-23-2021-28-AS-MVAO-CC5SJH-20220302125509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 11/23/2021
Date Signed: 11/23/2021 01:12:37 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
11/15/2021 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211115134302

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: 92	DATE:	11/23/2021
		UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Carlos Lara- Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff threatened to evict resident illegally.
Front door not working properly.
Elevators are not working properly.
Staff do not respond to pendents in a timely manner.
Food service is inadequate.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint visit to investigate the above allegations. LPA met with Administrator, Carlos Lara and explained the reason of the visit.

The investigation consisted of the following: LPA interviewed ten residents (R1-R10), administrator and five (5) staff (S1-S5) and obtained copy of the documents included residents roster, faciltiyn dining service menu, R1's Identifiction and Emeregency Information, Admission Agreement, Physician Report. Appraisal/Needs and Service Plan, Resident Appraisal and 30 day eviction notice dated on 10/9/2021.

The investigation revelaed of the following: Allegation#1 "Staff threatened to evict resident illegally." LPA interviewed ten residents and nine residents reported there are no staff ever threatened them.

(See LIC9099C for continuation)

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: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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-20211115134302

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: 11/23/2021

NARRATIVE

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Administrator reported the facility provided a 30 day eviction notice to R1's son via email who was his power of attorney and also denied ever threatening R1 about the eviction. R1's son also confirmed receiving the 30 day eviction notice via email and did notify R1 verbally and copy of notice was sent to R1 via text message.

Allegation#2 "Front door not working properly. " LPA interviewed ten residents and nine residents denied the allegation and reported the front door is working well and overall the building is working properly without any problems. LPA interviewed five staff and all denied the front door is not working properly. Staff stated no resident ever complained about the front door is not working good. Administrator reported due to COVID-19, the front door currently cannot be opened from outside because they have to control who's coming in and out but each facility resident has their own key to open the front door from outside.

Allegation#3 "Elevators are not working properly." LPA interviewed ten residents and nine residents reported both of the elevators in the facility are working well and never had any major issues. LPA interviewed five staff and all denied the allegation and reported the elevators are always working and no resident ever got stuck in the elevator. LPA also observed the two elevators in the facility and they are both working well.

Allegation#4 "Staff do not respond to pendents in a timely manner." LPA interviewed ten residents and nine residents denied the allegation and reported the staff are able to meet their needs. The staff never took two hours to respond the pendant. The residents reported the longest the staff took maybe only within 30 minutes. LPA interviewed five staff and all denied the allegation and reported when they saw the pendant/light on for the residents room, they usually go right away but sometimes they cannot leave the resident right away while they are assisting them.

Allegation#5 "Food service is inadequate." LPA interviewed ten residents and nine residents denied the allegation and reported the food is more than adequate. There's plenty of food for them to choose. They can get as much as they want and they never get hungry. LPA interviewed the staff and all denied the allegation. There's no resident ever complained about the food service is inadequate. Residents can always get second and they can choose the substitute food if they do not like the menu of the day.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211115134302

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: 11/23/2021

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	Based on LPA’s observations, interviews which were conducted and record review(s), 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 allegations are UNSUBSTANTIATED. Exit interview conducted. a copy of the report and appeal right was provided to administrator, Carlos Lara.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC9099 (FAS) - (06/04)

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