197609005-7-27-2023-28-AS-FFIS-CUDQLZ-20230804121645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609005
Report Date: 07/27/2023
Date Signed: 07/27/2023 04:52:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/17/2022 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220217112823

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: 97	DATE:	07/27/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator Carlos Lara		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident was not adequately supervised

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation above. LPA met with administrator Carlos Lara and the purpose of the visit was discussed.

Initial visit was conducted on 2/24/22 by LPA Kruz and consisted of the following: LPA obtained and reviewed a copy of the Staff Schedule (August, September, October and December 2021), Resident Roster, Resident #1's records (Physician report, Medical History, Resident Appraisal, Appraisal/Needs and Services Plan, Identification and Emergency Information).

On todays visit, LPA Villalobos toured the physical plant and interviewed Staff #1-#5 (S1-S5) and residents #2-#8 (R2-R8) , LPA unable to interview R1 as they are not available for to be interviewed. The investigation revealed the following:

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220217112823

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: GLEN TERRA ASSISTED LIVING	FACILITY NUMBER: 197609005
	VISIT DATE: 07/27/2023

NARRATIVE

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Regarding the allegation of "Resident was not adequately supervised" it was alleged that the resident had not been receiving adequate supervision as guaranteed by the facility. (5) of (5) Staff interviewed denied the allegation. (7) of (7) Residents interviewed could not corroborate the allegation. Interviews do not show that R1 received 1 on 1 supervision in the facility. LPA reviewed R1's Needs and Services plan, and did not observe R1 needing 1 on 1 supervision throughout the day. LPA did observe that R1 should be visited by staff throughout the day for various reasons. Interviews from staff stated that these visits were conducted regularly and R1 was assisted with anything they needed. LPA was not provided with proof of staff not providing supervision to R1 and R1 is unable to be interviewed. Based on files reviewed, observations, and interviews conducted, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit Interview conducted and a copy of this report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC9099 (FAS) - (06/04)

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