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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 04/22/2022
Date Signed: 04/28/2022 10:44:21 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2021 and conducted by Evaluator Gail Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210802105346
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: 83DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Carlos LaraTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility did not provide resident adequate supervision.
INVESTIGATION FINDINGS:
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On 04/22/2022 approximately 10:30 am, Licensing Program Analyst (LPA) Gail Johnson and Licensing Program Manager (LPM) Ulysses Coronel arrived at Glen Terra Assisted Living and conducted an unannounced complaint investigation. LPA and LPM met with Administrator Carlos Lara and the purpose of the visit was explained.

The investigation consisted of the following: On 08/10/2021 LPA Bonnie Tao interviewed five (5) staff and one (1) resident. LPA Tao obtained a copy of staff records and resident records. On 04/22/2022, LPA Johnson and LPM Coronel interviewed toured the facility, reviewed facility and client R1’s records and interviewed administrator Lara.

Report continues on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail JohnsonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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 5
Control Number 28-AS-20210802105346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GLEN TERRA ASSISTED LIVING
FACILITY NUMBER: 197609005
VISIT DATE: 04/22/2022
NARRATIVE
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Regarding the allegation: “Facility did not provide resident adequate supervision.” It is alleged that the facility failed to supervise R1 which resulted to R1 leaving the facility unassisted. On 04/22/22 reviews of R1’s physician’s report and needs and services plan indicate that R1 is not able to leave the facility unassisted. On 08/10/21 Administrator Lara stated that on 07/29/21 the facility door was left open by non-facility staff around 7:30pm. Staff discovered that R1 was missing between 8:05pm and 8:40pm. Regarding the allegation: “Facility did not provide resident adequate supervision.” The “preponderance of the evidence” standard has been met, therefore the allegation is Substantiated. Division 6 Chapter 8 is being cited, please see LIC9099D.

Plans of Correction were developed. An exit interview was conducted. A copy of this report and Appeals Rights were provided to Administrator Lara.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail JohnsonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210802105346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN TERRA ASSISTED LIVING
FACILITY NUMBER: 197609005
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
87705(I)(6)
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87705(I)(6) Care of Persons with Dementia. The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents.
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The administrator agreed to create a plan to ensure that Locked exterior doors or perimeter fences with locked gates will not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. Proof of correction will be submitted via email to gail.johnson@dss.ca.gov.
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This requirement was not met as evidenced by: Based on interviews & record done by LPA Tao the licensee did not ensure that locked gates do not substitute staff to meet supervision needs of residents, on 7/29/21 R1 left the facility unsupervised which poses a potential health & safety risk to residents in care.
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail JohnsonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2021 and conducted by Evaluator Gail Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210802105346

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: 83DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Carlos LaraTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility did not report resident missing.
INVESTIGATION FINDINGS:
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5
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On 04/22/2022 approximately 10:30 am, Licensing Program Analyst (LPA) Gail Johnson and Licensing Program Manager (LPM) Ulysses Coronel arrived at Glen Terra Assisted Living and conducted an unannounced complaint investigation. LPA and LPM met with Administrator Carlos Lara and the purpose of the visit was explained.

The investigation consisted of the following: On 08/10/2021 LPA Bonnie Tao interviewed five (5) staff and one (1) resident. LPA Tao obtained a copy of staff records and resident records. On 04/22/2022, LPA Johnson and LPM Coronel interviewed toured the facility, reviewed facility and client R1’s records and interviewed administrator Lara.

Report continues on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail JohnsonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20210802105346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GLEN TERRA ASSISTED LIVING
FACILITY NUMBER: 197609005
VISIT DATE: 04/22/2022
NARRATIVE
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The investigation revealed the following: Regarding the allegation: “Facility did not report resident missing. “It is alleged that “The facility did not report facility missing in a timely manner.” On 08/10/21 Administrator Lara stated that on 07/29/21, Staff reported that R1 was missing around 8:20pm and were instructed to look for resident within the facility and to call the police if not found within 10 minutes, in about 10 minutes the police brought resident back to the facility. Regarding the allegation: “Facility did not report resident missing.” The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

An exit interview was conducted. A copy of this report was provided to Administrator Lara.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail JohnsonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5