197609005-5-6-2021-28-AS-MVAO-C5KQ8F-20210804115639

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 05/05/2021
Date Signed: 05/06/2021 11:30:25 AM

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
02/19/2021 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20210219164146

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: 78	DATE:	05/05/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Administrator, Carlos Lara		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff neglect resulted in resident ingesting a foreign object.
Staff did not seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Linda Almaraz initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this complaint investigation was conducted telephonically with Carlos Lara, Administrator.

The investigation consisted of the following: On 2/25/21, LPA Almaraz interviewed Administrator and Staff #1-6. LPA also requested staff and resident roster, complete file for Resident #1, and staff schedule for the month of February 2021.

The investigation revealed the following: Interviews with staff and records reviewed revealed on 2/8/21, Resident #1 received the second dosage of the COVID-19 vaccine and started not feeling well or eating. The residents daughter was made aware and the daughter went to the facility and spent sometime with Resident #1. (Continued on LIC 9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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-20210219164146

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: 05/05/2021

NARRATIVE

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From 2/8/21 through 2/11/21, Resident #1 was not feeling well, had a sore throat and was weak. Per records reviewed, the daughter was contacted each day and was given status regarding the resident. The daughter asked the facility not to send the resident out to the hospital and to keep monitoring the resident because she felt it was side effects from the vaccine the resident had just received. On 2/12/21, the resident was having shortness of breath and oxygen levels had dropped. The facility called 911 and the resident was transported to hospital. The daughter was also notified. Regarding allegation "Staff did not seek medical attention in a timely manner" it is unsubstantiated.

During interviews conducted with staff, it revealed the resident was sent out to the hospital on 2/12/21 and was in the hospital for over a week. Sometime during the residents hospital stay a denture bracket belonging to the resident was found on the residents throat. During interviews conducted, LPA learned although the resident was not feeling well after receiving the second dosage of the COVID-19 vaccine, the resident never expressed any discomfort or pain days prior to being sent to the hospital or the day of. Per staff interviews and records reviewed, the resident was eating in small quantities and had no difficulty swallowing. Interviews also revealed the resident was somewhat independent and at times would only need assistance for bathing. Staff indicated the resident would sometimes conduct residents own oral hygiene and would remove the partial dentures for staff to clean. All interviews conducted stated the resident was never seen without the dentures on prior to being sent to the hospital. Some time in 2/20/21, the facility made contact with the hospital and the resident was stable and was going to be discharged. A day later the facility was notified by the residents daughter the resident had passed away. It is unknown if the resident ingested the denture bracket at the facility or the hospital. Regarding allegation "Staff neglect resulted in resident ingesting a foreign object" it is unsubstantiated.

Based on LPA's interviews conducted and records reviewed, investigation revealed: Although the allegations 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 allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted via telephone with the Administrator and a hardcopy was provided via email for signature. Signatures on hardcopy.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC9099 (FAS) - (06/04)

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