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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609005
Report Date: 08/16/2022
Date Signed: 08/16/2022 03:32:55 PM


Document Has Been Signed on 08/16/2022 03:32 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:
08/16/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Carlos Lara General Manager/Administrator TIME COMPLETED:
04:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted a continuation annual visit at the facility to review medication for residents. Initial visit was on 8/11/2022. LPA Met with Wellness Director Ana Tupinyan, Carlos Lara Administrator and Tony Rios Director of Community Relations and explained the reason for the visit.
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During this visit LPA reviewed medication for 8 residents. Medication was found in compliance. Staff files and residents’ files were not reviewed. During the initial visit LPA observed medication in room 201 and reviewed file to confirmed that resident can administer own medication.

LPA also did walk through and verified that POCs issued during initial visit were completed.

During today's visit LPA Lopez did not find any deficiencies.

Exit interview was conducted with Carlos Lara, Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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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