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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603165
Report Date: 06/03/2025
Date Signed: 06/03/2025 03:48:39 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/23/2025 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20250123164514
FACILITY NAME:GLEN PARK AT VALLEY VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:MARILOU MENDOZAFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: 48DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:David Aguiniga and Virginia Sumulong TIME COMPLETED:
03:46 PM
ALLEGATION(S):
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Staff do not ensure residents’ hygiene needs are met.
Staff did not follow residents’ needs and services plan.


INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to deliver the findings for the allegations listed above. The LPA met with the Executive Director David Aguiniga and Virginia Sumulong explained the reason for the visit

On 01/24/2025, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced 10-day visit to investigate the allegations listed above. The LPA met with the Executive Director David Aguiniga and Virginia Sumulong and explained the reason for the visit. At 10:37 a.m., LPA Urena requested records pertinent to the investigation, and conducted interviews from 10:35 a.m. to 11:34 a.m.

Continues on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
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 4
Control Number 29-AS-20250123164514
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT VALLEY VILLAGE
FACILITY NUMBER: 197603165
VISIT DATE: 06/03/2025
NARRATIVE
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Staff do not ensure residents’ hygiene needs are met.
It is alleged that the resident does not receive baths as needed. To investigate the allegation the LPA conducted interviews and requested records pertinent to the allegation. The residents’ interviews revealed that they receive showers two times a week and more if necessary. The facility administrator provided a calendar that indicates the day residents get assistance with showers, however the calendar did not indicate the time of the day when showers are provided. The interview with the staff revealed that they have scheduled days to assist residents with showers, and shower time is usually after breakfast or lunch. The staff stated that R1 required a two (2) person assist, and that the RP did not want a Hoyer being utilized for showers. The LPA interviewed the RP, and the RP stated that staff refused to give showers to R1 unless the RP was present. The RP stated that R1 is ambulatory with the assist of two (2) people.

Although the allegation may have happened or is valid, based on the interviews, and record review, there is not sufficient evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff did not follow residents’ needs and services plan.
It is alleged that the facility staff leave the resident unsupervised/unattended when the resident cannot be alone. To investigate the allegation the LPA reviewed pertinent records. Record review of the Physician’s Report (LIC 602) dated and signed on 09/20/2024, indicates that R1 is ambulatory, does not require continuous bed care, and is able to transfer independently to and from bed. The record review of the Appraisal/Needs and Services Plan (LIC 625) dated 11/26/2024, revealed that R1 needed total assist with Activities of Daily Living (ADL’s), was wheelchair bound and was non-ambulatory. Furthermore, the LIC 625 indicates that R1 needed assistance to attend activities in the Activity Room, staff was to assess R1’s needed due to R1 inability to express their needs, and staff was to assist with showers and medications and eating. However, the LIC 605 does not indicate that R1 cannot be left alone. The LIC 605 was signed by the RP and dated 11/26/2024.

Base on the information obtained through record review, there is not sufficient evidence to prove that R1 could not be left alone. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview was conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/23/2025 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20250123164514

FACILITY NAME:GLEN PARK AT VALLEY VILLAGEFACILITY NUMBER:
197603165
ADMINISTRATOR:MARILOU MENDOZAFACILITY TYPE:
740
ADDRESS:5527 LAUREL CANYON BLVDTELEPHONE:
(818) 769-6626
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:100CENSUS: DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:David Aguiniga and Virginia Sumulong TIME COMPLETED:
03:46 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure that an appropriately skilled professional is on duty to meet resident's needs for injectable medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
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13
Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to deliver the findings the allegations listed above. The LPA met with the Executive Director David Aguiniga and Virginia Sumulong explained the reason for the visit.

On 01/24/2025, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced 10-day visit to investigate the allegations listed above. The LPA met with the Executive Director David Aguiniga and Virginia Sumulong and explained the reason for the visit. At 10:37 a.m., LPA Urena requested records pertinent to the investigation, and conducted interviews from 10:35 a.m. to 11:34 a.m.

Continues on LIC 9099C...
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20250123164514
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT VALLEY VILLAGE
FACILITY NUMBER: 197603165
VISIT DATE: 06/03/2025
NARRATIVE
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Staff do not ensure that an appropriately skilled professional is on duty to meet the resident’s needs for injectable medications.
It is alleged that the facility staff did not respond in a timely manner to the RP regarding the qualified staff needed to provide medical care for R1 during the weekend since the facility does not have a skilled medical staff available on weekends to administer an injectable medication to R1. LPA Urena conducted interviews, and record review. The interview with the RP revealed that the Administrator stated that the facility did not have skilled medical staff to provide the injections to R1 once R1 returned to the facility from the hospital. Per the RP, R1’s physician was going to change one of the medications from tablet form to liquid form (injectable). Per the RP the facility staff stated that they had a License Vocational Nurse (LVN) during the week but not on weekends. The facility staff was going to look into getting a LVN to come out on weekends for the injectable medication. However, one day before the release of R1 from the hospital, the RP still had not heard from facility staff. The interview with the facility administrators revealed that they spoke with the RP about the injections and stated that the facility could not provide that type of service during the weekend, and that the LVN present at the facility Monday through Friday is for the oversight of medications assistance for all residents at the facility. The administrators stated that R1 was never on an injectable medication while R1 resided the facility prior to going to the hospital. Furthermore, R1 was discharged and returned to the facility without physician’s orders for the injectable medication. Record review of discharge papers revealed that R1 was admitted back to the facility on oral medications only.

Based on the information obtained through interviews and record review, R1 was never on an injectable medication while residing at the facility. Therefore, the allegation is deemed Unfounded at this time.

Exit interview was conducted. A copy of the report was issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4