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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 09/18/2025
Date Signed: 09/18/2025 01:54:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2025 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20250314081909
FACILITY NAME:GLEN TERRA ASSISTED LIVINGFACILITY NUMBER:
197609005
ADMINISTRATOR:RECORDS, TERRYFACILITY TYPE:
740
ADDRESS:917 N LOUISE STREETTELEPHONE:
(818) 291-1918
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY:155CENSUS: 100DATE:
09/18/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carlos Lara - Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Due to lack of supervision, resident had multiple falls with injury.
INVESTIGATION FINDINGS:
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At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced subsequent complaint visit. LPA met with the Executive Director Carlos Lara and explained the reason for the visit.

To investigate the allegation above LPA Rahimi, conducted an initial visit on 03/20/2025. During course of the investigation, interviews and record review were made. At 10:10 AM, LPA requested client and staff roster. At 10:15 AM, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:25 AM, LPA conducted a physical plant tour. Between 10:40 AM – 3:40 PM, LPA conducted an interview with the Executive Director (ED), a MedTech, a Licensed Vocational Nurse (LVN), two (2) staff, a Housekeeper, and eight (8) residents. During today’s visit, between 10:30 AM to 11:45 AM, LPA conducted additional interviews with five (5) residents.
Continue on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
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 31-AS-20250314081909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN TERRA ASSISTED LIVING
FACILITY NUMBER: 197609005
VISIT DATE: 09/18/2025
NARRATIVE
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Due to lack of supervision, resident had multiple falls with injury.

It was alleged that due to lack of supervision, Resident #1 (R1) had multiple falls with bruises and not enough assistance was provided based on R1’s need. To investigate this allegation on 03/20/2025, LPA conducted interviews with the Executive Director, Wellness Director/LVN, and two MedTechs, and it was revealed that R1 only had one known fall on 03/11/2025 and proper assistance was being provided by assessing R1 for injuries and pain. Additionally, on 03/12/2025, R1 was offered to be taken to the hospital; however, R1’s family refused to let the facility take R1 to the hospital and instead took R1 to the hospital themselves. Furthermore, LPA reviewed R1’s medical records and observed that on 03/13/2025, R1 was provided wound care consult at the hospital. During the wound care consult, it was revealed that due to the falls R1 had bilateral arms bruising and abrasions, redness to left breast, bilateral groin and perineal areas, right foot bruising on dorsal and planar area, and left knee/leg abrasion. Moreover, during the initial visit, LPA conducted a file review of R1 and observed that last Physician report was dated 05/23/2023, and R1 was diagnosed with Mild Cognitive Impairment and Fibromyalgia (impaired balance and muscle weakness). LPA also did not observe that the facility either notified R1's Physician nor updated the Appraisal Needs and Services Plan to meet and address R1’s needs appropriately. Lastly, during the initial visit on 03/20/2025, LPA interviewed eight (8) out of nine (9) residents, who confirmed that not enough assistance is being provided to meet their needs. During today’s visit, LPA interviewed five (5) additional residents and one (1) out of five (5) residents interviewed stated that their care needs are not being met. Therefore, based on interviews, medical records review, and R1's facility file review this allegation is Substantiated.

Deficiency issued and appeal rights explained.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250314081909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN TERRA ASSISTED LIVING
FACILITY NUMBER: 197609005
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities- (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful..... .
This requirement is not met as evidenced by:
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The Executive Director agreed to provide staff training on Personal Rights of Residents and will provide copy of the training materials to RO/LPA by the POC due date, which is 09/25/2025.
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Based on the interviews, medical record review and R1's facility file review the facility did not ensure to provide proper/enough care to R1 to prevent multiple falls which poses a potential risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC9099 (FAS) - (06/04)
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