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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609005
Report Date: 10/05/2021
Date Signed: 10/05/2021 11:18:22 AM

Document Has Been Signed on 10/05/2021 11:18 AM - 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, 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: 87DATE:
10/05/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Carlos Lara - Administrator TIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit regarding COVID 19 recommendations and guidelines. LPA Flores met with Carlos Lara administrator and explained the reason for the visit.

LPA Flores observed the following; upon arriving at the facility LPA Flores observed receptionist Jessica Almendarez in the receptionist desk with surgical mask under her chin, there were residents sitting in wheelchairs about 4 feet distance from the receptionist and other residents sitting in the lobby area.

Per PIN 21-38 ASC "All ASC residential facilities must sctrictly adhere to current CDPH Masking Guidance."

Deficiencies will be noted on LIC 809D per Title 22 Regulations. Civil Penalties were assess for a Repeat Violation within 12 months for the amount of $250.00.

Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2021
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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Document Has Been Signed on 10/05/2021 11:18 AM - It Cannot Be Edited


Created By: Mary G Flores On 10/05/2021 at 10:42 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN TERRA ASSISTED LIVING
FACILITY NUMBER: 197609005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2021
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in all Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful andcomfortable accommodations, furnishings and equipment.
This requirement is not met as evidence by:
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Administrator will ensure all staff are following COVID 19 recommendations and guidelines per state mandates at all times. Administrator will certify with LIC 9098 and
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Based on observation licensee is not ensuring receptionist is wearing a face mask at all times which poses an immediate personal rights, health, and safety risk to persons in care.
*Civil Penalities for Repeat Violation were assess in the amount of $250.*
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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:Rebecca Orendain
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2021


LIC809 (FAS) - (06/04)
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