197609005-10-27-2022-28-AS-MVAO-CL7VS8-20221115154106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 10/27/2022
Date Signed: 10/27/2022 10:24:29 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
09/22/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210922155543

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: 96	DATE:	10/27/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Carlos Lara, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident was exposed to amphetamines while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver the finding for the allegation listed above. LPA met with Administrator, Carlos Lara, and explained the purpose for the visit.

The investigation consisted of the following:
On 9/23/21, LPA Chan conducted the initial visit. LPA toured the facility with Administrator Lara and selected 10 residents' rooms to inspect. There were adequate food supplies of 2 days perishable and at least a week of non-perishable. LPA did not observe any health and safety concerns during the visit. LPA obtained copies of the staff roster, resident roster, and documents pertaining to Resident #1. The Department of Social Services Investigations Branch (IB) Investigator Peter Zertuche conducted a further investigation.

(continue on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210922155543

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN TERRA ASSISTED LIVING	FACILITY NUMBER: 197609005
	VISIT DATE: 10/27/2022

NARRATIVE

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The investigation revealed the following:
Allegation - Resident was exposed to amphetamines while in care. Interviews were conducted the Administrator, facility staff, Medical Professionals, Resident #1 (R-1), and Resident #1's family members. The Administrator and Staff were not aware of Resident #1 (R-1) having amphetamine drugs in the system until R-1's family reported it to the facility. At approximately 11am on a Friday, R-1's family member came to visit and saw resident on the floor. R-1 was later taken to the hospital and according to the medical records, the blood tests revealed a "presumptive positive" for amphetamines. Staff stated R-1 appeared to be fine and did not notice any unusual activity. R-1 was interviewed and stated that resident lost his/her balance and fell. R-1 also stated the doctor informed of drugs in his/her system but resident did not know who gave it and did not think that the staff or family member would have given the drug. A case was opened with the Glendale Police Department alleging that a family member provided the drugs to R-1. Per Detective Shores, the case is closed under no crime as there was no evidence to support the allegation.

Based on interviews completed by Investigator Zertuche, there were no witnesses to this allegation. Administrator and Staff did not know how amphetamines were found in R-1's system. They stated that family members are able to visit R-1 and allowed unmonitored visits. Family member denied giving drugs to R-1 during their visits. Family expressed they are happy with the care the facility is providing. Therefore, there is insufficient evidence to prove resident was exposed to amphetamines while in care.

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 the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Administrator Lara. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

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