197609005-2-22-2023-28-AS-MVAO-CPNSGZ-20230306125243

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 02/22/2023
Date Signed: 02/22/2023 01:14:02 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,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2023 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230117091626

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: 94	DATE:	02/22/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Carlos Lara		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Due to neglect residents developed pressure injuries while in care
Residents are left soiled for extended periods of time while in care
Residents are not being provided appropriate care and supervision while in care
Facility has insufficient staffing

INVESTIGATION FINDINGS:

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On 02/22/2023 Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation at the above facility to address the following allegations. LPA Agard met with Carlos Lara, Administrator and explained the purpose of this visit was to deliver findings for this complaint.

The investigation consisted of the following: LPA toured the physical plant. The facility is licensed to served 155 non - ambulatory residents, of which, 4 can be bedridden and has a hospice waiver for 20 residents. Facility is 4-stories in height, with a lobby, dining room located on the main floor, 2 activity rooms, kitchen, a small outdoor shaded patio, medication room located on the second floor, and a salon. LPA Agard conducted interviews and reviewed records on 01/18/2023 and 01/19/2023.

Cont. on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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-20230117091626

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN TERRA ASSISTED LIVING	FACILITY NUMBER: 197609005
	VISIT DATE: 02/22/2023

NARRATIVE

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The investigation revealed the following: Regarding the allegation… Due to neglect residents developed pressure injuries while in care. “It’s being alleged residents are left unattended in their rooms, not turned constantly, leading to open bed sores.” LPA interviewed 4 out of 45 staff in total. 0 out of 4 staff confirmed the allegation. S1 states, “there is only one person that’s on hospice. They have a small pressure wound and are receiving wound care from hospice. I want to say it’s at stage 2 right now.” S2 states, R1 has a wound that is just forming due to being bedridden, and she’s on hospice. The wound is very small. Hospice is taking care of the wound with me. I take care of it as well as hospice. I don’t think there are any other residents with a pressure ulcer.” S4 states, “the nurse takes care of the wound and we reposition every two hours. I don’t think the residents are neglected.”

During interviews with the resident, LPA Agard attempted interviews with 11 out of 89 residents in total. 0 out of 9 residents confirmed the allegation. 2 residents were unable to participate in the interview due to their cognitive ability. R2 states, “I haven’t observed anything like that. I’m never neglected, and I have a good time here. Everything is fine here with the girls.” R4 states, “no. I don’t know about that. People fall but that’s about it. I’ve never seen anything except for maybe a cut from a resident falling. I don’t feel like anyone is neglected here.” R6 states, “I don’t know anything about that claim.” R8 states, “I don’t know about any pressure injuries and no one is neglected from what I can see because I watched them.”

Regarding the allegation… Residents are left soiled for extended periods of time while in care. “It’s being alleged many residents are left sitting in wet diapers and clothing.” 0 out of 4 staff confirmed the allegation. S1 states, “our residents are checked every two hours. That’s our standard. We don’t have an actual incontinent schedule. We have to check everyone regardless. We check their diapers, briefs and offer assistance to the restroom.” S2 states, “I have not observed that. The caregivers check every two hours if they are soiled. It doesn’t matter if they are bedridden or incontinent. They have to be clean before going to breakfast.” S3 states, “residents aren’t left wet or soiled. We always try to change them every 2-3 hours. Especially the ones with sensitive skin. We know the incontinent people and the people that need more attention.” S4 states, “I don’t think so. The policy is that we need to assist each resident so we can’t leave the residents wet for long periods of time. We check every 2 hours. With some residents I check every 30 minutes.”

cont on 9099C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20230117091626

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN TERRA ASSISTED LIVING	FACILITY NUMBER: 197609005
	VISIT DATE: 02/22/2023

NARRATIVE

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LPA attempted interviews with 11 residents. 0 out of 9 residents confirm the allegation. 2 residents were unable to participate in the interview due to their cognitive ability. All residents interviewed unanimously denied the allegation or knowing anything about it. R3 states, “not that I know of.” R5 states, “that I don’t know. I never heard anyone say that.” R6 states, “I sure have not observed that.” R8 states, “they took care of me when I needed diapers.” R10 states, “I don’t think so.”

Regarding the allegation… Residents are not being provided appropriate care and supervision while in care. “It’s being alleged several residents are constantly neglected at the facility.” 0 out of 4 staff confirmed the allegation. S1 states, “we are providing very good care that’s why we are full. No residents really complain.” S2 states, “none, no, no one. Our residents are very verbal. They come to me with concerns.” S3 states, “I try to go above and beyond even if it’s not my assignment.” S4 states, “absolutely yes, if a patient needs something, we try to get it right away. If they have pain, we get the med tech if they need first aid. I don’t know why someone would say that. The families are always here too.”

0 out of 9 residents confirm the allegation. 2 residents were unable to participate in the interview due to their cognitive ability. R2 states, “the care here is fine. I don’t have any problems.” R4 states, “yes, absolutely. My needs are met.” R5 states, “I’ve been here for 6 years and I haven’t had that problem.” R6 states, “they are giving me good care, yes, they are 100%.” R8 states, “they take good care of me here.” R10 states, “I can’t think of any problems. They clean my room, make my bed and give me 3 meals per day?”

Regarding the allegation… Facility has insufficient staffing. 0 out of 4 staff confirmed the allegation. S1 states, “we aren’t low on staff; we have 7 caregivers on right now. In the evening we have 5. In Dec 2022, there were two times we only had 3 caregivers. It was the holidays.” S2 states, “actually, we are sufficient. We have 7 in the am, 5 in the pm and 3 overnight. I would say we are staffed with more than enough people to meet the needs.” S3 states, “I don’t think there is not enough staff. We are okay.” S4 states, “no that’s not true. We have 8 or 7 staff on shift. We usually never have less.”

1 out of 9 residents confirm the allegation. 2 residents were unable to participate in the interview due to their cognitive ability. R2 states, “90% of the time they are fully staff but there are call offs and the girls do a good job at “filling in the gaps. Overall, they do a good job.” R3 states, “no, not enough staff. Honestly, no. For the

cont on 9099C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20230117091626

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN TERRA ASSISTED LIVING	FACILITY NUMBER: 197609005
	VISIT DATE: 02/22/2023

NARRATIVE

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number of residents that need more care, they need more people to take care of them.” R4 states, “they probably could use more. I’m not saying they can’t do it. They make it work with what they have.” R5 states, “I don’t see any difference. I can’t really say. I hear people complain sometimes but not often.” R6 states, “I think they have enough. Everyone needs are being met from what I can see.” R7states,” I think there are enough people that work here. I don’t see a problem.”

During a record review, LPA Agard identified one resident that has or had a pressure injury in which they were being provided with wound care. R1 is currently receiving home health services that are addressing a stage 2 pressure ulcer. Hospice plan is dated for 11/30/2022-01/28/2023. LPA did not observe or identify any other residents with a pressure injury. LPA reviewed the resident care log for all residents for the month of January and found each resident was provided with the level of care needed, based on their care needs. LPA reviewed the staff schedule for the month of November and December 2022 and found the staffing patterns to be sufficient.

Based on LPA’s observation, record review and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of the report was given.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

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