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

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 01/28/2022
Date Signed: 01/28/2022 04:39:50 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 reporting COVID-19 cases.

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 allegations 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 reporting the Coronavirus (COVID-19) cases. Based on the interviews with the Administrator and Staff, they all indicated that if there are positive COVID-19 cases at the facility, everyone is informed. Staff are aware of the recently confirmed positive case. (Continue on LIC9099C)

Unsubstantiated

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 2

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

Per Administrator, when they have any confirmed COVID-19 cases, residents are informed through memos that are left outside their door mailboxes, families are informed, and notification to Community Care Licensing (CCL), Los Angeles County Public Health, and local Ombudsman. LPA interviewed 10 residents, and 4 out of the 10 stated the facility did not inform them about the positive COVID-19 cases. LPA verified that the most recent positive case was reported to CCL on 1/20/2022.

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.

An exit interview was conducted with the Administrator. A copy of this report along with the 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 2