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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609005
Report Date: 08/19/2021
Date Signed: 08/19/2021 03:31:59 PM

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:
08/19/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Carlos Lara - Administrator TIME COMPLETED:
04:00 PM
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Licensing Program Analyst(s) (LPA) Mary Flores and Luis Mora conducted a plan of correction (POC) visit for deficiencies cited on 8/3/21 and 8/10/21. LPAs met with Carlos Lara administrator and explained the reason for the visit.
On 8/321 LPA Flores conducted an annual inspection visit and on 8/10/21 LPA Flores conducted a case management annual continuation visit with focus on the infection control domain, a review of medication, and food review. During the visit LPA cited type A deficiencies due on 8/4/21 and 8/11/21.

Today's visit LPA Flores and Mora conducted a POC visit to cleared the deficiencies due on 8/4/21 and 8/11/21.
The following type A deficiencies were cited on 8/3/21 and 8/10/21:

87303(a) Maintenance and Operation: Facility failed to ensure the safety of the residents by maintaining social distancing during meals. This deficiency has been cleared as of 8/19/21.

87468(a)(2) Personal Rights: Facility failed to ensure staff is properly wearing face covering while providing care. This deficiency has been cleared as of 8/19/21.

87303(a) Maintenance and Operation: Facility failed to ensure room #219 bathroom was free of pest. Deficiency cleared as of 8/19/21.

87309(a) Care of Persons with Dementia: Facility failed to ensure an auditory system is in place to ensure the safety of residents with dementia in care. Facility currently serves 5 dementia residents. Deficiency not cleared.

Per Title 22 Regulations deficiency 80087(g)(1) has not been cleared. Facility failed to correct the deficiency therefore Civil Penalties have been assess for the following dates 8/12/21 to 8/19/21 for the total amount of $800.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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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