197609005-8-3-2021-28-AS-MGFS-C5JUWZ-20210803155733

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609005
Report Date: 08/03/2021
Date Signed: 08/03/2021 03:57:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 82	DATE:	08/03/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:04 PM
MET WITH:	Carlos Lara - Executive Director		TIME COMPLETED:	04:15 PM

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	Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit focusing on the infection control domain, food supplies. LPA(s) met with Carlos Lara Executive Director and explained the reason for the visit. Facility is licensed to served 155 non - ambulatory residents, of which 4 may be bedridden and has hospice waiver for 20 residents. . Facility is a 4 story building, with a lobby, dinning room, 2 activity room, a kitchen, a small outdoor shaded patio that is currently under renovation and not accessible to residents, medication room in the second, and a salon in the third floor. Fire alarm sprinkle system was observed throughout the facility. There are no large bodies of water in the property. LPA Flores conducted a walk through with Executive Director and observed the following: Facility is clean and free of odors in common areas observed. Kitchen - Facility has sufficient food of at least 2 days of perishables and 7 days of non-perishables. LPA observed residents lunch hour and there were 2 tables (1 square, 1 rectangle) sitting 4 residents, and other square tables sitting 3 residents which does not follow the recommended 6 feet apart per CDC - COVID 19 recommendations. Elevators are in working condition. LPA choose random rooms to observe and tested water temperature in each room: room #127 tested at 117.4, #118 tested at 116.9, #205 tested at 106.5, #215 tested at 118.7, #227 tested at 116.4, #219 tested at 120, #324 tested at 119.3, #322 tested at 118.2, #315 tested at 113.8, #305 tested at 108.9 #401 tested at 113.1 #407 tested at 118.2 degrees F which is within the recommended 105 to 120 degrees F. All bedrooms have the proper bedding, and furniture. LPA Flores observed the following in rooms #127 lysol wipes and PRN medication, room #227 lysol wipes, #219 ants in bathroom's sink LPA asked administrator to pull the emergency call cord 4 minutes after administrator and LPA walked to medication room to ensure light was on Wellness director stated to have notice light was on but there was no response, and in room # 322 LPA observed 3 empty oxygen tanks. (CONTINUED LIC 809C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 7 residents were having lunch in dinning room without proper 6 feet distancing which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2021
	Plan of Correction
1 2 3 4	Administrator will provide ensure there is social distancing being follow and will adjust residents to 2 per table will submit LIC 9098 to verify by 8/4/21.

Type A

Section Cited

CCR

87468.(a)(2)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 staff observed not wearing a face covering around other staff or residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2021
	Plan of Correction
1 2 3 4	Administrator will provide an in-service training regarding proper face covering use with all staff and will submit a copy of in-service and sign in sheet by 8/4/21.

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: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/03/2021

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Facility has COVID guidelines in place: such as screening of visitors, signs in front lobby, training related to infection control. LPA observed 3 staff; wellness director, a med tech, and activity director not wearing their mask around other staff or residents. Hand sanitizers dispensers are throughout the facility. There are no signs throughout the facility, staff bathroom and kitchen hand washing sink were missing proper hand washing sign.

LPA Flores was not able to conclude today's annual visit and will return at a further time to continue annual visit. Deficiencies cited today only reflect infection control domain, other deficiencies were observed were made on other domains and will be address in the next visit.

Per Title 22 Regulations Chapter 6 Division 8, deficiencies will be cited for today's visit in attached LIC 809D, technical violation, and Technical Advisory notes will be given.

Exit interview with Carlos Lara executive director was conducted and a copy of LIC 809D, tecnical violation/advisory, appeal rights were provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC809 (FAS) - (06/04)

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