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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609005
Report Date: 12/05/2022
Date Signed: 12/05/2022 04:29:43 PM

Document Has Been Signed on 12/05/2022 04:29 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: 96DATE:
12/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Carlos Lara TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Rea conducted a case management visit for the purpose of issuing a deficiency.

During the course of complaint investigation for complaint #28-AS-20221129161405, LPA observed that facility staff did not submit a special incident report following resident #1's fall on 8/9/22 and subsequent hospitalization.

Deficiency attached on 809-D.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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 12/05/2022 04:29 PM - It Cannot Be Edited


Created By: Angelica Rea On 12/05/2022 at 04:08 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: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2022
Section Cited
CCR
87211(a)(1)(B)

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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
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Administrator will ensure that special incident reports are submitted to community care licensing as required. Adminstrator will conduct staff training regarding reporting requirements and will submit proof of training to LPA by POC due date.
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This requirement is not being met as evidenced by: LPA observed during complaint investigation that Special Incident was not submitted for resident #1 fall and hospitalization.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022


LIC809 (FAS) - (06/04)
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