197609005-1-28-2022-28-AS-LHIS-CCZKCB-20220330074650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 01/28/2022
Date Signed: 01/28/2022 04:40:45 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
01/25/2022 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-NP-20220125080926

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:	ZIP CODE:	91207
CAPACITY:	155	CENSUS: 90	DATE:	01/28/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Carlos Lara, Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not following COVID-19 outbreak guidance.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with Carlos Lara, the Administrator. The purpose of the visit was explained.

The investigation consisted of the following:
LPA Chan toured the facility with the Administrator. LPA obtained copies of the staff and resident rosters, COVID-19 Mitigation Report, and In-Service training logs. LPA also interviewed the Administrator, 7 Staff, and 10 Residents.

The investigation revealed the following:
Regarding allegation, Facility is not following COVID-19 outbreak guidance. LPA toured the facility and observed the following pertaining to the allegation: The Staff are all wearing their surgical/N95 masks correctly.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

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 3

Control Number 28-NP-20220125080926

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: 01/28/2022

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

Although the residents are not required to wear masks, staff stated that residents are reminded at times but do not force residents if they do want to wear masks. LPA observed social distancing in the common areas which include the lobby, activity rooms, and dining room. Although the dining room and activity rooms are open, they have reduced the number of residents at one time to allow social distancing. Residents were observed sitting a few feet apart from each other while in the lobby area and while participating in the activities. The dining room had only 2 chairs for each table. All the staff interviewed stated that there are social distancing in place at the facility. 8 out of 10 residents said they observe social distancing. In regards to testing residents for the Coronavirus, none of the residents interviewed stated they have been tested for the COVID-19 virus recently. Per Administrator, they had only tested all the staff and about 30 residents recently for the confirmed COVID-19 case dated 1/19/22. According to the Community Care Licensing PIN 21-32.1-ASC, "As soon as possible after one (or more) COVID-19 positive individuals (resident or facility staff) is identified in a facility, perform serial retesting at least weekly with molecular testing or a minimum of twice weekly with antigen testing of all residents (excluding independent Continuing Care Retirement Community residents, unless they have been in communal settings with other residents) and facility staff, regardless of vaccination status. Serial retesting should continue to be performed until no new cases are identified in sequential rounds of testing covering a 14-day period." It was determined that the facility did not fulfill this testing guidance.

Based on LPA observations, interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-NP-20220125080926

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/11/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	The licensee shall review the Provider Information Notices PIN 21-32.1-ASC on testing guidance. In addition, the licensee shall perform weekly covid-19 testing to all staff and residents until no new cases are identified in sequential rounds of testing covering a 14-day period.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not ensure all the residents get the covid-19 testing which poses a potential health, safety, and personal rights to residents in care.	8 9 10 11 12 13 14	The licensee shall submitted a statement acknowledging the PIN has been reviewed and to ensure that testing are performed until the testing is fulfilled by POC due date 2/11/22.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3