197609084-8-17-2021-31-AS-CHAS-C6XLGM-20210917084458

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609084
Report Date: 08/17/2021
Date Signed: 08/17/2021 11:42:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2020 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20200520140621

FACILITY NAME:	PARKVIEW OF GLENDALE		FACILITY NUMBER:	197609084
ADMINISTRATOR:	WILKENS, DAVID		FACILITY TYPE:	740
ADDRESS:	426 PIEDMONT AVE		TELEPHONE:	(925) 377-5197
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91206
CAPACITY:	0	CENSUS: 0	DATE:	08/17/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jonathan Berg		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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1. Facility is charging for services not authorized
2. Staff is not following admission agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness contacted previous owners Jonathan Berg and Chris Berg to deliver the final findings of the allegations mentioned above. Jonathan Berg contacted LPA on 08/17/2021, and the following was determined

Allegation # 1: Facility is charging for services not authorized: Concerns were expressed, that the facility was charging for services not authorized by the responsible party/conservator for resident #1 (R1). On June 02, 2020 and July 16, 2020, from 8am to 4pm, LPA conducted interviews and obtained documents pertaining to the complaint. From various dates, ranging from September 18, 2020, through August 16, 2021, LPA reviewed emails, correspondences, medical reports, R1’s facility file, incident reports, and legal documents. Through all the information obtained, it was revealed and reported, that R1 left the facility on March 29, 2018, and March 02, 2020, and was missing for periods of time.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021

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 6

Control Number 31-AS-20200520140621

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PARKVIEW OF GLENDALE	FACILITY NUMBER: 197609084
	VISIT DATE: 08/17/2021

NARRATIVE

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Missing reports were filed with the local police department. Although R1’s medical reports and other documentation recommended R1 to move to a more secured environment R1’s conservator initiated and paid for a private caregiver from 03/05/2020 through 03/19/2020. The Administration from the facility, made the executive decision to continue the caregiver services without the permission from the conservator, and submitted invoices for payment to the conservator without authorization. It was also reported the facility refused to deposit monthly rental payments, because the conservator refused to pay the additional services the facility was trying to enforce. Further review of documents revealed, the facility did not properly conduct a completed assessment or updated needs and service/appraisal plan and did not provide in writing the purpose or reason for the additional services for a private caregiver. There was also no documentation observed in R1’s facility file. Therefore, based on interviews and documentation provided for the investigation, the allegation “Facility charged for services not authorized” is Substantiated.

Allegation # 2: Staff not following admission agreement: Concerns were expressed, that staff was not following their admission agreement. On June 02, 2020 and July 16, 2020, from 8am to 4pm, LPA conducted interviews and obtained documents pertaining to the complaint. From various dates, ranging from September 18, 2020, through August 16, 2021, LPA reviewed emails, correspondences, medical reports, resident’s (R1) facility file, incident reports, and legal documents. According to the admission agreement, it is documented, “The Community may terminate this agreement…if, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted…and the Community and the person who performs the reappraisal believe that the Community is not appropriate for the Resident…” The agreement also states, “upon admission, the Community shall provide each resident and representative or responsible person of each resident, with written information about the right to make decisions concerning medical care...such a copy shall be signed by the resident and the responsible party, if any, and included in the resident’s record…” From interviews and documentation obtained and reviewed, it was reported, R1 left the facility unattended on March 29, 2018, and March 02, 2020, and was missing for periods of time. Missing reports were filed with the local police department pertaining to R1. Although R1’s medical reports and other documentation recommended R1

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 31-AS-20200520140621

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PARKVIEW OF GLENDALE	FACILITY NUMBER: 197609084
	VISIT DATE: 08/17/2021

NARRATIVE

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to move to a more secured environment. It was reported that the facility had been trying to evict (R1), due to R1 leaving the facility unattended for hours and overnight. But there was no written (30) day notice provided or issued to R1 and the responsible party. The facility’s Administration requested R1 to have a private caregiver; without providing written documentation in explaining the reason or purpose R1 needed additional services. Although it was reported that R1 had (2) incidents of leaving the facility unattended and missing for periods of time, the facility did not properly conduct a completed assessment, or update a needs and service/appraisal, or reappraisal. Nor did the facility provide those documents to the R1’s responsible party in writing. There was also no documentation observed in R1’s facility file. Therefore, the allegation, “Staff not following admission agreement”, is SUBSTANTIATED.

Exit interview conducted and copy of report was emailed to former Licensee

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2020 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20200520140621

FACILITY NAME:	PARKVIEW OF GLENDALE		FACILITY NUMBER:	197609084
ADMINISTRATOR:	WILKENS, DAVID		FACILITY TYPE:	740
ADDRESS:	426 PIEDMONT AVE		TELEPHONE:	(925) 377-5197
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91206
CAPACITY:	0	CENSUS: 0	DATE:	08/17/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jonathan Berg		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility is unlawfully evicting resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness contacted previous owners Jonathan Berg and Chris Berg to deliver the final findings of the allegations mentioned above. Jonathan Berg contacted LPA on 08/17/2021, and the following was determined:

Allegation #1: Facility is unlawfully evicting resident: Concerns were expressed, that the facility was unlawfully evicting resident. On June 02, 2020 and July 16, 2020, from 8am to 4pm, LPA conducted interviews and obtained documents pertaining to the complaint. From various dates, ranging from September 18, 2020, through August 16, 2021, LPA reviewed emails, correspondences, medical reports, resident’s (R1) facility file, incident reports, and legal documents. Through all the information obtained, it was revealed and reported, that R1 left the facility on March 29, 2018, March 02, 2020, and was missing for periods of time. Missing reports were filed with the local police department, pertaining to R1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 31-AS-20200520140621

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PARKVIEW OF GLENDALE	FACILITY NUMBER: 197609084
	VISIT DATE: 08/17/2021

NARRATIVE

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Although R1’s medical reports and other documentation recommended R1 to move to a more secured environment. It was reported that the facility had been trying to evict (R1), due to R1 leaving the facility unattended for hours and overnight. According to the Administrator, an eviction notice was never issued. Review of documents obtained during the investigation, revealed, the facility did not issue an eviction notice to R1 or the conservator. Through other correspondences reviewed, the Administrator implied R1 relocate to another facility. But LPA never observed an issued (30) day written eviction notice. Therefore, based on documentation review and interviews, the allegation “Facility was unlawfully evicting resident”, is UNSUBSTANTIATED.

Exit interview conducted and copy of report emailed for former Licensee.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 31-AS-20200520140621

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PARKVIEW OF GLENDALE	FACILITY NUMBER: 197609084
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/17/2021 Section Cited CCR 87507(a)(B)(g)(6	1 2 3 4 5 6 7	Admission Agreements: (a)The licensee shall complete an written admission..(a)..with each resident or representative...(g) Admission agreements shall specify the following: (B) rate for additonal items	1 2 3 4 5 6 7	No POC, facility has ceased operation and closed. Residents have been relocated.
	8 9 10 11 12 13 14	...including: (6) The use of third-party services.. shall be explained...how they may be arranged..This requirement was not met, evidenced by: the facility did not properly conduct a completed assessment or updated needs and service/appraisal plan and did not provide in writing the purpose or reason for the additional services for a private caregiver. There was also no documentation observed in R1’s facility file.	8 9 10 11 12 13 14
Type B 08/17/2021 Section Cited CCR 87507(a)(B)(g)(5	1 2 3 4 5 6 7	Admission Agreement: (a)The licensee shall complete..written admission agreement..(a)..resident..or representative..(g)..shall specify the following: (B) Rate for...items and services..	1 2 3 4 5 6 7	No POC, facility has ceased operation and closed. Residents have been relocated.
	8 9 10 11 12 13 14	(5) A statement acknowledging the acceptance or refusal.. admission agreement was signed..shall be signed and dated..This requirement was not met, evidenced by: the facility did not properly conduct a completed assessment, or update a needs and service/appraisal, or reappraisal. Nor did the facility provide those documents to the R1’s responsible party in writing. There was also no documentation observed in R1’s facility file.	8 9 10 11 12 13 14

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 6