197609005-6-2-2023-28-AS-DSIS-CT2KMF-20230622080128

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 06/02/2023
Date Signed: 06/02/2023 10:41:23 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/28/2022 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220328103723

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: 98	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Carlos Lara - Administrator		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Resident sustained a fracture while in care

INVESTIGATION FINDINGS:

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***This report is a corrected version of the report dated 04/04/2023 due to a correction needed to the LIC9099D. Citation 87466 was incorrectly issued as a Type B citation, citation should have been issued as a Type A. The other citation 87405(d)(1) on report dated 04/04/23 was issued correctly. No other changes were made to the report. The complaint investigation findings remain Substantiated.***

Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint subsequent visit to render finding for the above allegation. LPA met with Receptionist Cecilia Espinoza and explained the reason of the visit. Shortly after, LPA met with Health and Wellness Director Anna Tupinyan and assisted with the visit.

The investigation consisted of the following: On 3/29/2022, LPA conducted an initial complaint visit and a health and safety check. LPA toured the facility with Administrator and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Restrooms, handwashing basins, toilets and bathtub/showers are operable. There are no immediate health and safety concerns. The following documents were collected which included: staff and resident roster and documents for Resident#1-#3.
(See LIC 9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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 3

Control Number 28-AS-20220328103723

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: GLEN TERRA ASSISTED LIVING	FACILITY NUMBER: 197609005
	VISIT DATE: 06/02/2023

NARRATIVE

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The complaint was accepted by Community Care Licensing Investigation Branch (CCIB) and it was assigned to IB investigator Christine Ferris. Investigator Ferris interviewed resident (R1), Administrator (S1), R1’s Power of attorney, Health and Wellness Director, two residents, private caregiver and R1’s primary physician. USC Verdugo Hills Hospital and Glendale Memorial Hospital medical records were obtained.

The investigation revealed the following: “Resident sustained a fracture while in care”, based on interviews conducted, facility documents, and medical records obtained from USC Verdugo Hills Hospital and Glendale Memorial Hospital by investigator Ferris, the findings noted R1 had multiple falls from September 2020 to March 2022 which resulted in serious injuries including a fractured finger, a fractured arm, and a fractured neck and back. During the interview, R1 stated that all the injuries were accidental. The result of R1’s falls also happened during the evening when there was no 1:1 caregiver present. On September 2020, R1’s doctor had already recommended that R1 required one on one care and it would be neglectful if R1 does not have a one on one to use the bathroom, move and from the bed and wheelchair, or getting dressed. Although R1 had a private caregiver who works seven days a week from 10am to 5pm from December 2020 to April 2022. The facility also implemented safety checks every two hours, beginning and end of shift and gave a resident a pendant to call for help, however R1 misplaced the pendant. Facility failed to take any action after each incident involving a fall for R1 to mitigate the falls.

Based on LPA’s interviews, and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

***An immediate Civil Penalty of $500.00 is being issued today, due to the facility failed to observe changes in resident’s health which resulted in resident sustained a fracture while in care. Refer to LIC 421IM***

At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(e) & (f) and may be assessed at a later date.

An exit interview was conducted, and a copy of this report and appeal right were provided to the Wellness Director Anna Tupinyan along with the Appeals Rights.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220328103723

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: GLEN TERRA ASSISTED LIVING	FACILITY NUMBER: 197609005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/03/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident.. The licensee shall ensure...observed for changes in physical, mental, ...functioning .... appropriate assistance is provided...physical health condition are observed, the licensee shall ensure that such changes are documented...resident's responsible person, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Administrator to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	Based on interviews conducted, the facility did not take any action to mitigate the falls for R1. R1 had multiple falls from September 2020 to March 2022 which resulted in serious injuries, this poses an immediate risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

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