197609005-9-22-2026-31-AS-GSAO-DY6RWS-20260922132337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609005
Report Date: 09/22/2026
Date Signed: 09/22/2026 01:24:25 PM

Document Has Been Signed on 09/22/2026 01:24 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GLEN TERRA ASSISTED LIVING		FACILITY NUMBER:	197609005
ADMINISTRATOR/ DIRECTOR:	CARLOS LARA		FACILITY TYPE:	740
ADDRESS:	917 N Louise ST		TELEPHONE:	(818) 291-1918
CITY:	Glendale	STATE: CA	ZIP CODE:	91207
CAPACITY: 155		CENSUS: 95	DATE:	09/22/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Carlos Lara,Executive Director		TIME VISIT/ INSPECTION COMPLETED:	01:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/22/26, at 8:50AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced One (1) year, Required visit at this facility. LPA met with Executive Director, Carlos Lara and explained the reason for the visit. At 9:15AM, with the assistance of the Executive Director, LPA toured the facility inside and out and the following was observed: The facility is a four (4) storey building fire cleared for 155 non-ambulatory residents, four (4) of which may be bedridden and has hospice waiver for twenty (20) residents. The facility's smoke alarms are hard wired and interconnected. The fire extinguishers throughout the facility hallways are on all four (4) floors, all extinguishers were last serviced on 05/2026. The evacuation plan/emergency plan, Ombudsman, and YES sign are located by the mailboxes in front of the facility on the first floor. Surrounding Grounds: The outdoor/patio areas are located at the front and beside the dining room. There is a fish tank in front of the facility. There are two (2) elevators in the facility and evacuation chairs in the stairways. The activity room is located on the first floor and had a large television with and Activity Calendar. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. There was a listing for residents that require a special diet is posted on the kitchen wall. Kitchen/food service staff observed with gloves and proper hair cover. LIC 809C-continued

Troy Agard
Gina Saucedo
	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/22/2026

NARRATIVE

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Bedrooms/Bathrooms: Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Emergency push button was tested for proper function. Resident bathrooms were properly supplied and had functional fixtures. Hot water temperature in random resident bathrooms on all floors were checked and measured at a range of 115.0°F to 115.2°F. The facility temperatures varied at 72, 73°F.

Common Areas: Common areas, including the lobby, activity rooms, dining rooms, and reading room appeared clean and were properly furnished. There is a coffee/hot beverage station at the reading room with daily snacks. Salon was closed and locked during the day of the visit. There are cameras in the common areas.

Laundry: Each floor has it's own designated laundry area for personal clothing of residents. The main laundry area is located on the first floor beside the employee's lounge. All the laundry areas have equipped washers and dryers with chemicals.

Administration: Administrator's office is located on the first floor, by the entrance. Medication room and nurses' office on the second floor. Fire/earthquake and emergency evacuation drill is conducted on monthly basis for different shift and the last one was conducted ton 09/01/26. The administration Certificate expires on 10/2028 and the Liability Insurance expires on 06/2027.

Resident Files/Staff Files: LPA conducted a file review of nine (9) resident records. LPA also conducted a file review of six (6) staff records. There is no LIC 405 for residents and/or safeguarding of cash resources.

Medications: There are medication carts stationed at the medication/nurses' room. There is a refrigerator, with lock, in the medication room to store medicine that requires refrigeration. Medication room is also locked and inaccessible to residents. The facility uses Centrally Stored and Destruction Record and MAR-Medication Administration Records. There is a First aid kit on each medication cart and another by the reception area.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

LIC809 (FAS) - (06/04)

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