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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609005
Report Date: 08/11/2022
Date Signed: 08/11/2022 04:33:06 PM


Document Has Been Signed on 08/11/2022 04:33 PM - It Cannot Be Edited

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 LIVINGFACILITY NUMBER:
197609005
ADMINISTRATOR:RECORDS, TERRYFACILITY TYPE:
740
ADDRESS:917 N LOUISE STREETTELEPHONE:
(818) 291-1918
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY:155CENSUS: 94DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Dir of Community Relations Toni RiosTIME COMPLETED:
04:39 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Alberto Lopez conducted an unannounced annual visit focusing on the infection control domain. LPA was greeted by front desk receptionist Cecilia Espinosa and took tour of facility with driver Rosa Bibian. Director of Community relations Toni Rios showed up later and LPA 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, dining room, 2 activity room, a kitchen, a small outdoor shaded patio

,medication room in the second floor, 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 Lopez conducted a walk through with Driver Rosa Bibian and observed the following:


Facility is clean and free of odors in common areas. Elevators are in working condition. LPA choose random rooms to observe and tested water temperature in each room: room #406 tested at 105, bathroom sink tested at 104.9 #402 tested at 105.2 , #307 bathroom sink tested at 103.5, #318 tested at 108.1, #331 tested at 107.4, #232 tested at 107.2, Coffee room tested at 105.5 #221 tested at 106.3, #201 tested at 105., #105 tested at 105, #131 tested at 108.9.

All bedrooms have the proper bedding, and furniture. LPA inspected outside and inside of facility and doors where dumpsters are housed are in disrepair and off the frames. 7 day perishable food has most of it with expired dates and 2 day perishable food (vegetables) was old and state.

LPA was not able to complete the annual visit and will return another day to complete. Deficiencies cited for today’s visit (see 809D for details)

Exit interview conducted and copy of report left with Directo of community Relations Toni Rios

SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 08/11/2022 04:33 PM - It Cannot Be Edited

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: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above Room 406 water temperture in bathroom sink measure 104.9 and in room #307 the sink in living room measure 103.5 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2022
Plan of Correction
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Licensee will adjust water temperture and send proof of correction and certify that water temperture is within range by POC date.
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensse did not comply with the above. LPA and Staff observed spoiled lemons in lemon box and stale lettuce and celery which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2022
Plan of Correction
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Licensee will discard old stale vegtables and replace if necessary with fresh ones and send proof to LPA by POC date.

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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 08/11/2022 04:33 PM - It Cannot Be Edited

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: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observati some cans of non perisible food had expired which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2022
Plan of Correction
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Licensee will inspect all non perisible food and discard expired ones and replace if neccesary and send proof to LPA as POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/11/2022 04:33 PM - It Cannot Be Edited

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: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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
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Based on observation, the two double doors which house the dumpsters are unattached at the frames which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2022
Plan of Correction
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Licensee will repair or replace the doors that house the dumpster bins and send photo as proof to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4