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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603165
Report Date: 04/06/2022
Date Signed: 04/06/2022 04:22:21 PM

Document Has Been Signed on 04/06/2022 04:22 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GLEN PARK AT VALLEY VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:PINK TILLMANFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 100CENSUS: 36DATE:
04/06/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Janyce PinkTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Ashley Smith and Elsie Campos arrived at the facility unannounced at 10:30 a.m. for an annual continuation. The annual was initiated on 1/26/2022. The LPAs met with Administrator Janyce Pink and explained the reason for the visit.

PERSONNEL RECORDS: Personnel records were reviewed from 11:00 a.m. – 11:50 a.m. The LPAs reviewed ten (10) files for but not limited to: job application, health assessments, criminal record statements and clearances, first aid certification, applicable training. The following was observed: four out of ten staff (S1, S2, S4, S5) did not have a medical assessment with tuberculosis screening results, and three out of ten care staff (S2, S3, S5) require an up-to-date first aid certification. The Administrator’s Certificate expires 6/10/2023. In addition, whereas the facility had training documents for staff, they were not in order at the time of the visit. Technical violation issued.

RESIDENT RECORDS: Resident records were reviewed from 12:05 p.m. to 1:00 p.m. The LPAs reviewed nine (9) files for, but not limited to: admissions agreements, medical assessment, needs and service plans. Out of the nine files reviewed, four out of nine residents (R1, R2, R3, R4) needs an updated appraisal.

MEDICATIONS: Medications review took place from 1:30 p.m. – 2:30 p.m. Medications are located locked and inaccessible in the medication room. The LPAs conducted a medication audit for five (5) out of nine (9) residents. Within the audit, one out of five residents (Resident #5) has a medication that is being administered, but could not be located at the time of the visit.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. Administrator Janyce Pink was notified of the report findings; staff Jessyca Munoz was authorized to sign the report.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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 04/06/2022 04:22 PM - It Cannot Be Edited


Created By: Ashley Smith On 04/06/2022 at 03:29 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE
FACILITY NUMBER: 197603165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/22/2022
Section Cited
CCR
87411(f)

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87411(f) Personnel Requirements - General. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. Obtain the health screenings for the four staff, and submit to CCL by 4/22/2022.
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Based on record review, the licensee did not comply with the section cited above in four out of ten staff (S1, S2, S4, S5), which poses a potential health and safety risk to residents in care.
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Request Denied
Type B
04/22/2022
Section Cited
CCR87411(c)(1)

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87411(c)(1) Personnel Requirements - General. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. Obtain the valid first aid certification forms for the three staff, and submit to CCL by 4/22/2022.
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Based on record review, the licensee did not comply with the section cited above in three out of ten staff (S2, S3, S5), which poses a potential health and safety risk to residents in care.
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/06/2022 04:22 PM - It Cannot Be Edited


Created By: Ashley Smith On 04/06/2022 at 03:34 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT VALLEY VILLAGE
FACILITY NUMBER: 197603165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/07/2022
Section Cited
CCR
87465(a)(4)

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87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. Locate the medication for Resident #5. Inform CCL when this has happened, but no later than 4/7/2022.
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Based on record review, the licensee did not comply with the section cited above in one out of nine residents (R5), which poses an immediate health and safety risk to residents in care.
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Request Denied
Type B
04/22/2022
Section Cited
CCR87463(c)

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87463(c) Reappraisals. The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff ... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first ...
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. Complete the updated appraisals for the four residents, and submit proof of completion to CCL by 4/22/2022.
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Based on record review, the licensee did not comply with the section cited above in four out of nine residents (R1, R2, R3, R4), which poses a potential health and safety risk to residents in care.
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
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