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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609005
Report Date: 08/10/2021
Date Signed: 08/10/2021 04:19:18 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/10/2021 04:19 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
197609005
ADMINISTRATOR:RECORDS, TERRYFACILITY TYPE:
740
ADDRESS:917 N LOUISE STREETTELEPHONE:
(818) 291-1918
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY: 155CENSUS: 83DATE:
08/10/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Carlos Lara Executive Director TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted a continuation annual visit at the facility to visit initiated on 8/3/21 to review medication for residents. LPA Met with Carlos Lara executive director and explained the reason for the visit.
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During this visit LPA reviewed medication and files for residents #1(R1),#2(R2)I,#3(R3), #4(R4),#5(R5),#6(R6), #7(R7),#8(R8). Medication was found in compliance. During file review LPA observed facility serves a dementia resident. However facility does not have an auditory device system to prevent dementia residents from leaving the facility and/or a dementia unit. LPA observed that R6 is not able to manage own medication per physician, during the initial visit LPA observed lysol wipes in her room. Empty oxygen tanks have not been properly removed from room #322. During the initial visit of 8/3/21 LPA Flores observed ants in room #219.

During today's visit LPA Flores is citing deficiencies found on the attached LIC 809D and providing advisory notes.

Exit interview was conducted with Carlos Lara Executive Director and a copy of this report was provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2021 04:19 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/10/2021 at 03:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN TERRA ASSISTED LIVING
FACILITY NUMBER: 197609005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2021
Section Cited
CCR
87309(a)

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87705 Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.



This requirement is not met as evidence by:
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Licensing will ensure that an auditory device or other staff alert feature is in place to monitor exits, will certify by LIC 9098 by 8/11/21 and will submit a copy of invoice of auditory device or picture of such by 8/13/21
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Based on observation, documents reviewed facility serves dementia population, and residents may be able to open the front door and exit at any time which poses an immediate health, safety, or personal rights risk to persons in care.
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Type A
08/11/2021
Section Cited
CCR87303(a)

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87303(a) Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidence by:
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Administrator will contract pest control services will certify by LIC 9098 by 8/11/21 and provide a copy of invoice of services provided to room #219 by 8/13/21.
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Based on observation facility did not ensure room #219 is free of ants which poses an immediate health, safety, or personal rights riskto persons 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.
SUPERVISOR'S NAME:Rebecca Orendain
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2021


LIC809 (FAS) - (06/04)
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