197609005-12-5-2022-28-AS-RORN-CM4NQR-20221214094022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 12/05/2022
Date Signed: 12/05/2022 04:27:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/29/2022 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221129161405

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:	12/05/2022
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Carlos Lara		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident is left unattended
Facility staff did not accompany resident to the hospital
Facility interfering with resident's medical care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with Administrator Carlos Lara, who assisted with the visit.

The investigation consisted of the following: Interview(s) with Administrator, Staff #1 - Staff #3, Resident #1, Resident #1's son, Resident #1's companion, and review of resident #1's file.

Regarding the allegation that resident #1 is left unattended and that facility staff did not accompany resident #1 to the hospital, the investigation revealed that resident #1 has lived at the facility since October 9, 2021. Resident #1 experienced a fall on 8/9/22, when she was going to a doctor appointment on her electric wheelchair. Resident #1 suffered a fractured tibia and was hospitalized. Review of resident #1's physician's report does not indicate that resident #1 is not able to leave the facility unassisted. Administrator and facility staff interviewed stated that resident #1 always refuses to have any facility staff assist her on her medical appointments.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

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 2

Control Number 28-AS-20221129161405

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/05/2022

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
26
27
28
29
30
31
32

Regarding the allegation that facility is interfering with resident #1's medical care, Administrator and staff interviewed denied the allegation. They stated that resident #1's doctor called and spoke with staff #1 after resident #1's fall, and advised that resident should have a caregiver accompany her on doctor appointments. Administrator and staff stated that they are now ensuring that resident #1 has someone accompany her on appointments and outings. Resident #1 confirmed that since she fell, she is no longer going to her appointments by herself. Resident #1 stated that she does not believe the facility is interfering with her medical care.

Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Administrator, Carlos Lara.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2