197609005-8-27-2021-28-AS-WSHO-C7BVBN-20210929161750

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 08/27/2021
Date Signed: 08/27/2021 03:42:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2021 and conducted by Evaluator Nune Margaryan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210412091729

FACILITY NAME:	GLEN TERRA ASSISTED LIVING		FACILITY NUMBER:	197609005
ADMINISTRATOR:	RECORDS, TERRY		FACILITY TYPE:	740
ADDRESS:	917 N LOUISE STREET		TELEPHONE:	(818) 291-1918
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91207
CAPACITY:	155	CENSUS: 87	DATE:	08/27/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator: Carlos Lara		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not safeguard resident's personal property

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Nune Margaryan and Tony Vasallo conducted subsequent visit to the facility to further investigate the above noted allegation. LPAs met with Administrator Carlos Lara and explained the purpose of this visit.
It was alleged that facility resident #1’s (R1’s) personal property was stolen at the facility. The stolen items include wedding ring and “stimulus card”.
The initial visit was conducted by LPA Joe Katrdzhyan on 04/21/21. During the visit LPA Joe Katrdzhyan obtained the following documents:
• Admission Agreement • Pre-placement Appraisal Information • Appraisal/Needs and Services Plan
• Physician's Report • Functional Capability Assessment • Client/Resident Personal Property and Valuables Form • Resident Roster • Staff Roster
Today's investigation consisted of the following: Request Resident's and staff roster; obtained theft and loss policy, interviewed five (5) staff and eight (8) residents.
con. 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

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 2

Control Number 28-AS-20210412091729

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 197609005
	VISIT DATE: 08/27/2021

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
26
27
28
29
30
31
32

The investigation reveal the following:
Documents revealed that R1 or their responsible party refused to inventory their personal belongings the time of admission. Interviews conducted with the residents did not corroborate the allegation. Residents denied having any valuable items missing from the room. Staff interviewed denied the allegation. They did not have any information that staff has stolen from the residents.
When Administrator learn about allegation, called the police and made a report.

Based on LPA's observations, interviews and documents reviewed the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED.

Exit interview held. A copy of the report provided to Anahit Tupinyan.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2