197609005-7-28-2023-28-AS-FFIS-CUB2S3-20230801173826

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 07/27/2023
Date Signed: 07/28/2023 03:43:21 PM

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
05/04/2021 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210504155709

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: 97	DATE:	07/27/2023
		UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Administrator Carlos Lara		TIME COMPLETED:	02:44 PM

ALLEGATION(S):

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Facility has inadequate record keeping

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation above. LPA met with Administrator Carlos Lara and the purpose of the visit was discussed.

Initial visit was conducted on 5/13/21 by LPA Kruz and consisted of the following: LPA obtained a copy of the staff and resident roster, hospice agency information and interviewed Staff #1 and Staff #2.

On todays visit, LPA Villalobos toured the physical plant and interviewed Staff #3-#5 (S3-S5) and residents #2-#8 (R2-R8) , LPA unable to interview R1 as they are not available for to be interviewed. The investigation revealed the following:

Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-4939
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: 323-980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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 5

Control Number 28-AS-20210504155709

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: 07/27/2023

NARRATIVE

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In regards to the allegation of "Facility has inadequate record keeping" it was alleged that the the facility file for R1 was not available for review as it could not be located in the facility. (4) of (5) Staff interviewed could not provide information regarding the allegation. (7) of (7) Residents interviewed could not corroborate the allegation. Details state that a Long Term Care Ombudsman staff requested documents for R1 from the facility on April-May 2021. Staff interview confirmed that the file for R1 was not able to be provided as it could not be located in the facility. Initial visit interviews conducted on 5/13/21 by LPA Kruz confirms that that R1's file could not be located in the facility. R1 was discharged from the facility on 10/25/18 and per regulations the file for R1 should have been kept for a minimum of 3 years from that date. This means R1's file should have been on site and available for review until 10/25/21. Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.

Exit Interview conducted and a copy of this report was provided. Appeal Rights were discussed and provided as well.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-4939
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: 323-980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20210504155709

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: 07/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/10/2023 Section Cited CCR 87506(e)	1 2 3 4 5 6 7	87506 Resident Records.(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This was not met as evidenced by:	1 2 3 4 5 6 7	Facility to conduct in service training for management staff regarding Title 22 Regulations on Resident Records. Sign in sheet of start participating to be provided to CCL by POC due date.
	8 9 10 11 12 13 14	R1 was discharged on 10/25/18 and file for R1 was requested in April and May of 2021 but staff could not provide the file. This shows a potential health and safety risk for residents in care and supervision.	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: Fernando Fierros	TELEPHONE: (323) 981-4939
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: 323-980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
05/04/2021 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210504155709

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: 97	DATE:	07/27/2023
		UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Administrator Carlos Lara		TIME COMPLETED:	02:44 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-4939
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: 323-980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20210504155709

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: 07/27/2023

NARRATIVE

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In regards to the allegation "Resident sustained unexplained injuries while in care" it was alleged that R1 sustained unexplained bruising in their arms and legs. (5) of (5) Staff interviewed denied the allegation. (7) of (7) Residents could not corroborate the allegation. LPA Villalobos reviewed the hospice agency notes for R1 and did not observe documentation of bruising to R1's legs or arms. Notes stated that R1 was receiving wound care on their arm and their wrist. Staff interviews do not show that R1 was injured by any staff or to have observed R1 injured themselves. LPA was not provided with documentation of R1 having unexplained injuries in the facility. At the time of this visit, there is no resident file for R1 as the facility only keeps records for a minimum of 3 years and R1 has not been a resident since 10/25/18. Based on files reviewed, observations, and interviews conducted, there was not enough supportive evidence to corroborate the allegation. 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.

Exit Interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-4939
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: 323-980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5