<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 07/21/2021
Date Signed: 07/21/2021 03:06:19 PM

Unsubstantiated


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
07/16/2021 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210716081320
FACILITY NAME:GLEN TERRA ASSISTED LIVINGFACILITY NUMBER:
197609005
ADMINISTRATOR:RECORDS, TERRYFACILITY TYPE:
740
ADDRESS:917 N LOUISE STREETTELEPHONE:
(818) 291-1918
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY:155CENSUS: 82DATE:
07/21/2021
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Executive Director Carlos Lara TIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not assist resident with their medication in a timely manner
Staff did not assist resident with their toileting needs in a timely manner
Staff did not assist resident with their oxygen administration in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jose Villalobos initiated a complaint investigation for the allegation(s) listed above. Today’s complaint investigation was conducted with Administrator Carlos Lara and purpose of the visit was discussed.

Today's investigation consisted of the following: LPA Villalobos interviewed staff #1-#4 (S1-S5) and residents #1-#6 (R1-R6). LPA also obtained and reviewed copies of the following documents in reference to R1; Admission Agreement • Pre-placement Appraisal Information • Appraisal/Needs and Services Plan
• Physician's Report • Resident Roster • Staff Roster

Todays investigation revealed the following: In regards to the allegation " Staff did not assist resident with their medication in a timely manner" it was alleged that staff took more than an hour to provide R1 with their medication on 7/16/21 after reaching out to them.

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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-20210716081320
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: 07/21/2021
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
(5) of (5) staff interviewed denied the allegation. (5) of (6) residents interviewed could not corroborate the allegation. Review of documents show that R1 received medications scheduled at 8am 12pm 5pm and 8pm on 7/16/21. Based on interviews conducted and records reviewed there is not enough evidence to corroborate the 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 this allegation is unsubstantiated.

In regards to the allegation "Staff did not assist resident with their toileting needs in a timely manner" it was alleged that staff took more than an hour to assist R1 with their toileting needs on 7/16/21. (5) of (5) staff interviewed denied the allegation. (5) of (6) residents interviewed could not corroborate the allegation. LPA observed facility caregiver staff assisting R1 with their toileting needs between 11:30am-12:pm. R1 could not provide LPA with more information on times that staff would have taken long to assist but did state staff arrive to assist multiple times throughout the day. Based on interviews conducted and records reviewed there is not enough evidence to corroborate the 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 this allegation is unsubstantiated.

In regards to the allegation "Staff did not assist resident with their oxygen administration in a timely manner" it was alleged that staff did not assist R1 with their oxygen administration in a timely manner on 7/16/21. (5) of (5) staff interviewed denied the allegation. (5) of (6) residents interviewed denied the allegation. Review of R1's file show that R1 requires oxygen management. R1 stated to LPA that staff assist with the oxygen management daily. Staff interviews show that staff will check on R1 multiple times throughout the day as they are aware of R1's needs. Based on interviews conducted and records reviewed there is not enough evidence to corroborate the 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 this allegation is unsubstantiated.


No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted with Executive Director Carlos Lara and a hardcopy was provided via email for signature. Signatures on hardcopy.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2