Glen Park at Valley Village

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Elsie Campos and Salia Walker arrived at the facility unannounced to conduct a required annual visit at 9:25 a.m. This annual had a specific emphasis on infection control practices and procedures. Upon arrival, the LPAs observed one (1) sign posted on the from entrance door noting “Due to increase in COVID cases and for protection of our residents there will be no visitation allowed. Facility is closed to any outside personnel, please give us a call if you would like to speak to a resident and/or employee (818)769-6626. Thank you for your understanding. -Glen Park in Valley Village.” At 9:26 a.m., the LPAs observed two (2) additional signs posted on the right front entrance window noting “ATTENTION ALL VISITORS: AS OF 3/11/2020, IN ORDER TO PREVENT THE INTRODUCTION OF COVID-19 INTO OUR COMMUNITY, WE ARE RESTRICTING ALL NON-ESSENTIAL VISITORS. MORE INFORMATION WILL BE PROVIDED AS WE CONTINUE TO GET UPDATES”; and a reference page with no source provided indicating that there is a Visitation Waiver: “Facility may limit entry to only individuals who need entry as necessary for prevention, containment, and mitigation measures.” There have been various updated CDSS PINS since 3/11/2020. The facility should be implementing the most recent CDSS PIN 22-04-ASC “UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19).” The LPAs advised the Assistant Administrator, and Executive Director that visitation is allowed, as long as the facility follows the visitation requirements per PIN 22-04-ASC. Upon arrival, the LPAs initially met with staff. At 12:00 p.m., Executive Director Tillman Pink, and Assistant Administrator Janyce Pink were observed to have arrived at the facility, and were explained the reason for the visit. The LPAs conducted a physical plant tour with Staff #1 (S1) at 9:35 a.m., to ensure there are no health and safety hazards. Continue on LIC 809C.. Kitchen: The facility kitchen area appeared clean and sanitary. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food in the refrigerator/freezer were properly labeled. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. The LPAs were unable to measure the Hot water temperature due to the facility heater being in need of repairs. Bedrooms: The LPAs observed resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. Restrooms: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPAs observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. The resident bathrooms and shower rooms are properly equipped with grab bars and non-skid material. At 9:40 a.m., the LPAs attempted to measure the hot water temperature in the facility common restrooms. The LPAs were then advised that the facility heater was “down” since yesterday 1/25/2022. The LPAs inquired what measures the facility has taken for repairs. S1 advised that staff reported the needed repairs to management. Assistant Administrator Janyce Pink and Executive Director Tillman Pink stated that the facility water heater broke down on 01/25/22, and repairs were made the same day. According to Mr. and Mrs. Pink, the facility water heater broke down again today, and the individuals working on the heater were at the facility today. The LPAs were unable to measure the Hot water temperature due to the facility heater being in need of repairs. Common Areas: Fire extinguishers were observed throughout the facility and were fully charged with a service date of 08/25/21. The building is a two-level facility, which consists of offices, activity rooms, medication room, laundry room, multiple supply closets, beauty parlor, staff room, kitchen/dining room, and multiple shower rooms. The LPAs observed common areas, including furniture and activity equipment, to be clean and in good condition. A separate Food Storage room contains additional nonperishable, and perishable food items. Surrounding Grounds: Entry/exits were free of obstruction. Medication room: First aid kit, medications, and medication records are kept in the medication room. The First Aid Kit was complete with a thermometer, scissor, tweezers, bandage and a first aid manual. BACKYARD: The patio has covered outdoor areas equipped with furniture for resident use. There were no bodies of water noted. Continued on LIC 809-C.. INFECTION CONTROL: During today’s visit, the LPAs spoke with the Assistant Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPAs did not observe an adequate supply of Personal Protection Equipment (PPE). The executive director and assistant administrator were advised that the facility is able to obtain additional supplies from CCLD as needed as the RO has continued to support licensed facilities through the pandemic without interruption. During the physical plant tour, the LPAs observed that the facility does not have a sufficient 30-Day supply of PPE gear for staff and resident use. Between 12:03 p.m. and 12:15 p.m., it was confirmed based on LPAs observations that the facility does not have sufficient supplies of PPE gear based on LPAs observation of the physical plant. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. During the visit today, S1 informed us that the facility currently has two (2) COVID-19 Positive cases. The LPAs inquired with Staff #2 (S2) if the facility has not reported the COVID-19 Positive Cases to CCLD. S2 confirmed that the COVID cases were not reported to CCLD within 24 hours. At 10:05 a.m., the LPAs were advised by S1 that the facility has had five (5) to six (6) COVID-19 Positive cases in the past month that were unreported. For that reason, the facility management has prohibited all visitors to the residents as of approximately three (3) weeks ago. The LPAs advised the assistant administrator, and executive director that the facility is to report all COVID Positive cases to CCLD per Title 22 Reporting Requirements which threaten the welfare, safety or health of residents within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. The assistant administrator and executive director stated that the facility faxed the incident reports pertaining two (2) residents being positive for COVID-19 to the Woodland Hills North Regional Office (818)596-4376. The LPAs requested to see the fax sheet reflecting the incident reports were successfully faxed to the RO by the facility. The LPAs explained to Mr. and Mrs. Pink that our Department does not have records of incident reports submitted noting Positive COVID cases for January 2022. The Executive Director Tillman Pink stated that "no where in Title 22, does it state that we have to provide you the proof of fax sheet." The LPAs advised Mr. and Mrs. Pink of facility’s policies and procedures as it pertains to infection control which was agreed upon in the facility's Mitigation Plan. Continue on LIC 809C.. During the physical plant tour, the LPAs took note of the staff that were working at the time of the visit. During the visit, the LPAs encountered two (2) individuals who identified themselves as staff. The LPAs conducted a record review and confirmed that staff #3 (S3) and staff #4 (S4) are not associated to the facility nor were they indicated on the staff schedule. During the visit Executive Director Tillman Pink stated that S3 is not a staff at the facility, and has no knowledge of the alleged staff that claimed to be the facility's maintenance worker. Tillman Pink confirmed the facility's current maintenance worker is on leave. Executive Director Tillman Pink and Assistant Administrator Janyce Pink denied claim that S3 works at the facility. However, facility staff confirmed that S3 works for the facility, and completes maintenance assignments throughout the facility as needed. Staff also confirmed that S3 has worked in the facility for several months. The Licensee was previously cited for non-association of staff under section 87355(e)(2) on 12/21/21. Therefore, the facility is being cited for a repeat violation due to S3 and S4 not being associated to facility. Civil Penalties assessed. While discussing the findings from today's visit, Executive Director Tillman Pink stated to the LPAs he will be refusing to sign the report, and will be appealing the deficiencies; as well as making a formal complain against the LPAs. During the visit, LPAs Walker and Campos returned to the facility once more to deliver the findings to the assistant administrator and executive director. Staff advised the LPAs Mr. and Mrs. Pink departed from the facility, they are not authorized to sign the report, and that the facility does not have a Designee to sign today's report. Staff also stated that the only people authorized to sign the report were the assistant administrator and executive director, Mr. and Mrs. Pink. The LPAs attempted to contact assistant administrator Janyce Pink via telephone twice. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations Title 22. Civil Penalties assessed. Failure to correct deficiencies may result in additional Civil Penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 26, 2022

Allegation investigated: Illegal Eviction.

Licensing Program Analysts (LPAs) Elsie Campos and Ashley Smith arrived unannounced for an initial 10-day complaint visit. The LPAs met with Office Manager Elizabeth Flores and explained the reason for the visit. During today’s visit, the LPAs spoke to staff at 11:40 a.m. and 11:58 a.m.; spoke to residents at 12:21 p.m., 1:21 p.m., 1:23 p.m., 1:29 p.m.; 1:40 p.m. and 1:45 p.m. In addition, the LPAs reviewed documents pertinent to the investigation. Cont. on 9099-C Substantiated Regarding the above allegation, it was alleged that Resident #1 (R1) received an illegal eviction notice. Interviews with staff and R1 revealed that R1 was served an eviction notice on 12/16/2021. However, the eviction notice was dated as being issued on 12/2/2021, and the effective date was 1/02/2022. As such, R1 was not allotted a full thirty (30) days to vacate as required by law. Lastly, the eviction notice did not include language as specified in Health and Safety Code Section 1569.683(a)(4), nor did it include information for R1 to file a complaint with the licensing agency or the State Long Term Care Ombudsman office. Based on the information obtained, this allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Dec 21, 2021 · control 29-AS-20211217161220

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a) · Plan of correction due date: Dec 22, 2021

87224(a) Eviction Procedures. The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required… This requirement is not met as evidenced: Based on interview and record review, the licensee did not comply with the section cited above, as the issued eviction notice to R1 was invalid, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 21, 2021

Plan of correction: Administrator agreed to do the following: 1.Rescind the eviction notice within the next 24 hours. This must be done in writing. Submit proof to CCL by 12/22/2021 2.Create a valid eviction notice for R1 and submit the eviction notice to CCL for prior approval. Notice must be completed no later than 12/31/2021.

Allegation investigated: Facility did not ensure resident signed an Admission Agreement Staff are not providing a comfortable environment for resident

Licensing Program Analysts (LPAs) Elsie Campos and Ashley Smith arrived unannounced for a subsequent complaint visit. The LPAs met with Office Manager Elizabeth Flores and explained the reason for the visit. During the initial visit on 12/16/2021, the LPA’s conducted a brief facility tour at 1:50 p.m., interviewed resident at 2:00 p.m., interviewed staff at 2:18 p.m. and reviewed documents at 1:28 p.m. During today’s visit, the LPAs spoke to staff at 11:40 a.m. and 11:58 a.m.; spoke to residents at 12:21 p.m., 1:21 p.m., 1:23 p.m., 1:29 p.m.; 1:40 p.m. and 1:45 p.m. Cont. on 9099-C Unsubstantiated Allegation: Facility did not ensure resident signed an Admissions Agreement Regarding the complaint, it was alleged that Resident 1 (R1) did not sign an Admissions Agreement. During today’s visit the LPA’s interviewed R1 in which R1 admitted they signed an admissions agreement but was not clear of the contents. During the initial visit conducted by the LPA’s on 12/16/21 a copy R1’s signed admissions agreement was obtained. After reviewing the admissions agreement, it was determined that R1 had signed and initialed all required areas of the admissions agreement. Based on the investigation, this allegation is deemed unsubstantiated at this time. Allegation: Staff are not providing a comfortable environment for resident Regarding the complaint, it was alleged that staff were not providing a comfortable environment for Resident 1 (R1) because they were being issued invoices. Additionally, R1 was feeling uncomfortable due to their inability to pay. An interview with R1 revealed that R1 felt that staff were doing their jobs and acted in a professional manner when issuing the invoices and requesting payment. R1 denied claims that staff were being rude, disrespectful, or demeaning. Interviews with randomly selected residents revealed that staff are respectful and act professionally. Based on the investigation, this allegation is deemed unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 21, 2021 · control 29-AS-20211208140455

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Elsie Campos and Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20211217161220. During a visit conducted on 12/16/2021, it was observed that Staff #1 (S1) was not associated to the facility, and a file review confirmed that S1 started working at this facility on or about 08/04/2021. A civil penalty was issued on 12/16/2021, noting that S1 could not return to the facility until the association was complete. During today's visit, S1 was observed to be working at this facility. The LPAs reviewed the Caregiver Background Check System during today’s visit and observed that S1 was not associated to this facility. Per the staff schedule, S1 worked on 12/17/2021, 12/18/2021, and today, 12/21/2021. At the start of the visit, the LPAs observed the posted Administrator Certificate for the Administrator Pink Tillman III (#6009095740) to be expired. The LPAs checked the Administrator Application Status online and did not observe the Administrator’s name on either the active or pending list. Throughout the visit, the LPAs observed signs alerting staff and residents that ‘Janyce Pink’ was the new Assistant Administrator, effective immediately. However, S2 is not associated to this facility, nor does the Department have any paperwork, designating S2 as an Administrator. An internal file review revealed that this facility sent in an LIC9182 Caregiver Background Transfer Request on 12/20/2021. However, this facility did not include a completed LIC508 Criminal Record Statement or clear copy of S2s ID to complete the association. The date of employment on the association document was 11/23/2021. As of today, S2 is fingerprint cleared but is not associated to this facility. Interviews revealed that S2 began working in this facility on or about BLANK. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted, today's reports and appeal rights were issued. Civil penalties assessed.the state’s words, verbatim · CDSS document, Dec 21, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Dec 21, 2021

87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as S1 and S2 have not been associated to the facility, which which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 21, 2021

Plan of correction: The Executive Director Tillman Pink agreed to do the following: 1. Ensure that S1 and S2 are associated to the facility prior to allowing S1 and S2 to return to work. S1 and S2 will not work at the facility until proof of association is obtained.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87406(a) · Plan of correction due date: Dec 31, 2021

874069A) Administrator Certification Requirements. (a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as the current Administrator Certificate for the current Administrator on file is expired, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 21, 2021

Plan of correction: The Administrator agreed to do the following: 1. Identify a current Administrator; submit the required documents to CCL by 12/31/2021

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Elsie Campos and Teresa Camara conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20211208140455. During the file review, the LPAs audited the file for Staff #1 (S1) and Staff #2 (S2) and noted that S1 and S2 were not associated to the community. After reviewing the Caregiver Background Check System, it was noted that S1 and S2 have background check clearance, but neither are associated to this facility. A review of personnel records for S1 confirmed that S1 started working for this facility on or about August 4, 2021. A review of personnel records for S2 confirmed that S2 started working for this facility on or about April 10,2020. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties assessed.the state’s words, verbatim · CDSS document, Dec 16, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Dec 17, 2021

87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as S1 and S2 have not been associated to the facility since 08/04/21 (S1) and 04/10/20 (S2), which which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 16, 2021

Plan of correction: The Executive Director Tillman Pink agreed to do the following: 1. Ensure that S1 and S2 are associated to the facility prior to allowing S1 and S2 to return to work. S1 and S2 will not work at the facility until proof of association is obtained.

Allegation investigated: Resident has scabies Adequate food service is not provided to residents Residents diapers not changed in a timely manner Staff handles resident in a rough manner Facility did not ensure changes in resident's condition were reported to the responsible party.

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegations above. LPA met with facility staff and explained the reason for this visit. Resident has scabies It is alleged that a resident had scabies. This allegation has already been investigated previously with regards to complaint control number 31-AS-20200218121919. It was determined on 2/4/21 that the allegation was deemed Unsubstantiated. This allegation was alleged on 2/19/20. During the course of the investigation it was found that there was a small scabies outbreak and that the Department of Public Health was notified and residents who had scabies were isolated according to protocol. This allegation is deemed Unsubstantiated at this time. Unsubstantiated Adequate food service is not provided to residents It is alleged that residents are not provided good food service. LPA conducted interviews with residents regarding this allegation from approximately 3:20-4pm. LPA also toured the facility kitchen and checked the food supply from 3-3:20pm. Information from interviews revealed that residents are fine with the food service that is provided by the facility. Based on the information obtained through interviews and observation this allegation is deemed Unsubstantiated at this time. Residents diapers not changed in a timely manner It is alleged that residents who require assistance with incontinence care are not changed in a timely manner. LPA conducted interviews with residents who require assistance with incontinence care from 3:20-4pm. Information obtained from interviews conducted reveal that there has been no recent issues with residents being changed in a timely manner. Based on the information obtained this allegation is deemed Unsubstantiated at this time. Staff handles resident in a rough manner It is alleged that residents who require assistance with incontinence care are handled roughly. LPA conducted interviews with residents regarding this allegation from 3:20-4pm. Information obtained from interviews reveal that staff are not handling residents in a rough manner. Based on the information obtained this allegation is deemed Unsubstantiated at this time. Facility did not ensure changes in resident's condition were reported to the responsible party. It is alleged that facility did not contact resident #1 (R1) responsible person when they went to the hospital. Interviews revealed that this alleged incident happened on 2/16/20. During that time there was a different administrator working at the facility. Despite numerous attempts LPA was unable to contact the former administrator regarding that allegation. Staff interviewed stated they believed R1's responsible party was contacted. Due to not having enough information this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.the state’s words, verbatim · CDSS document, Dec 4, 2021 · control 31-AS-20200219141501

Allegation investigated: Facility staff failed to provide adequate food service Facility staff are not trained to meet the needs of the residents. Insufficient staffing Facility staff failed to assist residents in a timely manner Facility staff threatened resident

Licensing Program Analyst(s) Wendell Smith and Jose Gary Tan conducted an unannounced subsequent visit to investigate the allegations above. LPA met with the assistant administrator and explained the reason for this visit. Facility failed to provide adequate food service It is alleged that facility staff failed to bring food up to resident's rooms when they were sick. LPA's conducted interviews with residents from approximately 9:15-10:25am regarding this allegation. LPA's also conducted a tour of the facility kitchen and checked the food supply. LPA's observed there to be a sufficient amount of perishable and non perishable food. Based on the information obtained through interviews and observation this allegation is deemed Unsubstantiated at this time. Unsubstantiated Facility staff are not trained to meet the needs of the residents. It is alleged that facility staff are not properly trained to serve the residents. Interviews were previously conducted with facility staff. LPA's randomly reviewed staff records for three staff from approximately 10:30-11am and observed them all to have the proper trainings. Based on the information obtained through interviews and record review this allegation is deemed Unsubstantiated at this time. Insufficient staffing It is alleged that the facility does not have enough staff. LPA's previously obtained a staff schedule and interviews were conducted with staff. LPA's conducted interviews with residents from 9:15-10:25am regarding this allegation. Based on the information obtained this allegation is deemed Unsubstantiated at this time. Facility staff failed to assist residents in a timely manner It is alleged that residents are not being assisted when they need help from staff. LPA's conducted interviews the residents from 9:15-10:25am. Interviews revealed that there were no issues with residents being assisted in a timely manner. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time. Facility staff threatened resident It is alleged that a resident was threatened by staff. There was not a specific resident or staff mentioned in this allegation. LPA's interviewed residents and asked them have they witnessed any residents being threatened and all interviewed stated they had not. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time. Exit Interview conductedthe state’s words, verbatim · CDSS document, Dec 3, 2021 · control 31-AS-20200225090656

Type of visit: Case Management - Incident

On November 9, 2021, Licensing Program Analyst (LPA) Ashley Smith met with Executive Director Tillman Pink for a Case Management visit to issue a civil penalty per Health and Safety (H&S) Code §1569.49. On September 10, 2017, the Department received two incident reports from Glen Park at Valley Village. The first incident report stated that an 83-year old male resident (R1) was hospitalized on September 7, 2017 due to difficulty breathing and unresponsiveness. The second incident report stated that on September 10, 2017, administrators verified that the medication technician (S2) admitted to a medication error. On September 15, 2017, the Department received a death report from Glen Park at Valley Village reflecting that R1 passed away on September 13, 2017. The Department conducted an investigation which revealed that on the morning of September 7, 2017, staff 1 (S1), whom was not trained in assisting residents with the self-administration of medications, placed Resident 2’s (R2) medications on a dining room table between R1 and R2. R2 was prescribed 12 medications. The following are medications with possible adverse effects (harmful or undesirable effects) which could have contributed to R1’s sudden change in condition: 1. Duloxetine HCL 30 mg (antidepressants, neuropathic pain agent) - myocardial infarction, GI bleeding, nausea, vomiting, dizziness, lethargy, syncope, hypotension) 2. Clonazepam 0.5 mg (benzodiazepines, antianxiety) - coma, dyspnea, chest pain, palpitations, respiratory depression, drowsiness, dizziness) 3. Divalproex Sodium 500 mg (anticonvulsants, mood stabilizers) - coma, irregular heartbeat, chest pain, palpitations, hypotension, drowsiness, nausea, vomiting, dizziness, lethargy) 4. Benztropine 1 mg (anticholinergic, antispasmodic) - delirium, psychosis, drowsiness, dizziness 5. Clozapine 100 mg (antipsychotics) – seizures, irregular heartbeat, stroke, atrial fibrillation, cardiac arrest, hypertension, delirium, dizziness, syncope (Classifications and side effects listed. Pdr.net – medication reference used) R1’s regular prescribed medications were Hydrocodone (opioid for moderate to severe pain) Doc-Q-lace (stool softener), Pantoprazole (proton pump inhibitors), and Prednisone (costicosteroids). According to interviews, S1 witnessed R1 ingest R2’s medications and reported the medication error to S2 only. S2 admitted to not reporting the incident to any administrative staff, but advised S1 to closely monitor R1 every 30 minutes. Staff also reported R1 did not leave R1’s room at lunch time. On September 8, 2017, the administrator (S3) heard a rumor that S1 and S2 may have been responsible for R1’s hospitalization. On September 10, 2017, S3 and the assistant administrator (S4) interviewed S1 and S2, who admitted to the medication error. On September 7, 2017, R1 was found breathing, but unresponsive in his room. When staff, S5 and S6, tried to sit R1 up, he began vomiting and emergency response was called. According to medical reports, R1 was admitted to the hospital on September 7, 2017 at 4:41 p.m. with acute encephalopathy and presumed sepsis of unknown etiology. He was given 2 mg of Narcan, which improved his respiratory rate. Upon learning of the medication error, S3 informed the hospital on September 10, 2017. The Associate Medical Director of Palliative Medicine stated in her progress note that it appeared “the patient’s altered mental status and respiratory failure were due at least in part to the medication error (multiple drug-drug interactions with CNS and respirator depression and other potential adverse effects.” Per Mayo Clinic, sepsis is a “potentially life-threatening complication of an infection, and occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail.” R1’s family requested comfort measures only due to R1’s (Do Not Resuscitate/Do Not Intubate (DNR/DNI) order. R1 expired on September 13, 2017 at 6:07 p.m., and an autopsy was performed. According to the autopsy report dated September 21, 2017, R1’s official cause of death was acute bronchopneumonia with coronary artery atherosclerosis, nephrosclerosis, and medication toxicity. On September 11, 2017 at approximately 1:30 p.m a case management visit was conducted and the Licensee was cited for Title 22 California Code of Regulations (22 CCR) § 87411(a) Personnel Requirements - General which states, “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” On September 15, 2017 at approximately 3:30 p.m., the Licensee was cited for Title 22 CCR § 87465(g) Incidental Medical and Dental Care Services which states, “9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident’s health, including an apparent life-threatening medical crisis.” Additionally, § 87465(h)(2) Incidental Medical and Dental Care Services was cited which states, “Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication.” Today, on November 9, 2021 an additional citation is issued under Health & Safety (H&S) Code §1569.69(a)(1) Employees assisting residents with self-administration of medication; training requirements which states, “Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment.” On September 15, 2017, the licensee was informed that a civil penalty of $15,000 might be assessed based on H&S Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation resulting in a resident’s death. This is evidenced by facility staff failure to complete all required medication training prior to assisting residents with the self-administration of medications, and staff’s failure to immediately telephone 9-1-1 and inform medical professionals of the medication error which led to the hospitalization and death of R1. Exit interview conducted. A copy of the report issued. Appeal rights provided. Mr. Pink's signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.the state’s words, verbatim · CDSS document, Nov 9, 2021

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.69(a)(1) · Plan of correction due date: Nov 9, 2021

1569.69(a)(1) Employees assisting residents with self-administration of medication; training requirements. ... The employee shall complete 24 hours of initial training. ...16 hours of hands-on shadowing training... and 8 hours of other training or instruction ... This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as staff failed to complete all required medication training prior to assisting residents with the self-administration of medication for R1, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 9, 2021

Plan of correction: S1 and S2 are no longer employed with this community. Facility has ensured that staff complete medication training prior to assisting residents with the self-administration of medication. Plan of Correction met.

Allegation investigated: Facility staff failed to provide resident's records to resident's authorized representative – Substantiated

Licensing Program Analyst (LPA), Martha Guzman Chavez conducted a subsequent complaint visit to the above facility. The purpose of the visit is to conclude an investigation initiated by LPA Heffernan on 04/01/2020. On today’s visit, LPA Guzman Chavez met with Assistant Administrator Elizabeth Torres as Administrator Tillman Pink III was unavailable in a meeting. Entrance interview was conducted. During the initial visit on 04/01/2020, LPA Heffernan conducted a telephonic interview with Administrator, Rafael Silva between 9:18am and 9:42am. LPA Heffernan also requested copies of the medical records and a written statement from the facility’s attorney advising the facility what to do regarding the request for records. On 10/12/2021, LPA Guzman Chavez conducted a subsequent visit to the facility and interviewed current Administrator Tillman Pink at 3:30pm. Additional pertinent documentation was obtained and reviewed during the course of the investigation. (...Continued on LIC 9099C...) Substantiated (...Continued from LIC 9099...) It was alleged that on 03/20/2020, “Facility staff failed to provide resident's records to resident's authorized representative.” It was reported that on 03/23/2020, a Letter to Preserve Evidence was sent Glen Park at Valley Village by the attorney representing the Power of Attorney (POA) of a resident. Additionally, a request for Medical Records was also sent to the Custodian of Records at Glen Park at Valley Village on 03/02/2020. Interviews conducted revealed that documents were not released to the requesting party within the time allotted by regulations. Furthermore, interviews and documentation reviewed revealed, that that documents were held from POA per facility attorney stating, “Glen Park is not allowed to legally provide copies of any residents file without documented permission to ‘Release Medical Information’ signed by the Resident/Residents Power of Attorney.” However, records reviewed revealed that the representing attorney of the POA submitted all necessary documents along with request. Based on interviews and documents obtained, the allegation “Facility staff failed to provide resident's records to resident's authorized representative” is deemed substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D) Exit interview conducted, citations issued, appeal rights discussed, and a copy of this report sent via email.the state’s words, verbatim · CDSS document, Oct 19, 2021 · control 31-AS-20200323095639

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(19) · Plan of correction due date: Oct 29, 2021

Additional Personal Rights of Residents in Privately Operated Facilities. (19) To have prompt access to review all of their records and... photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement was not met as evidenced by: Based on interviews, and record review, the licensee did not meet the above section by failing to produce requested records resulting in a potential risk to the personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 19, 2021

Plan of correction: The Licensee has agreed to do the following: 1. Third party training and acknowledgment in Title 22, Division 6, Chapter 8. 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities by 10/29/2021.

Allegation investigated: Staff hit resident while in care - Unsubstantiated Resident is not afforded privacy while in care – Unsubstantiated

Licensing Program Analyst (LPA), Martha Guzman Chavez conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 06/22/2020 by LPA Brian Balisi and a subsequent visit was conducted on 08/09/2021 by LPA Guzman Chavez. On today’s visit, LPA Guzman Chavez met with Assistant Administrator Elizabeth Torres as Administrator Tillman Pink III was unavailable in a meeting. Entrance interview was conducted. During the initial visit on 06/22/2020, LPA Balisi conducted a telephonic interview with Administrator, Rafael Silva between 1:45pm and 2:45pm. On 08/09/2021, LPA Guzman Chavez conducted a physical plant tour with Assistant Administrator, Elizabeth Torres at 2:50pm and conducted four resident interviews between 3:00pm and 4:15pm. On 10/12/2021, LPA conducted five staff interviews between 2:07pm to 2:42pm, seven resident interviews between 2:44pm and 3:25pm, and then interviewed Administrator, Tillman Pink III at 4:15pm. (...Continued on LIC 9099C...) Unsubstantiated (...Continued from LIC 9099...) During the course of the investigation, LPA was unable to determine R2’s identity through staff and resident interviews. Also, R1 no longer resides at the facility and S1 no longer works at this facility, both were unreachable for interviewing. Additionally, LPA Guzman Chavez conducted interviews with North Los Angeles County Regional Center (NLACRC) on 08/30/2021 at 11:24am. Pertinent documentation was also obtained and reviewed during the course of the investigation. It was alleged that on 04/28/2020, staff hit a resident while in care. It was reported that on 04/28/2020, at approximately 4:30am, there was an incident that occurred between Resident #1 (R1) and Resident #2 (R2) at the facility. Staff #1 (S1) intervened as R1 went into the other residents’ room and started to record the two residents. R1 became upset at S1 and slapped S1 who in return slapped R1. Interview with the Administrator revealed that on 04/28/2020, there had been no physical altercation, however, there was a verbal altercation between R1 and S1. Interview with NLACRC representative revealed that there was no incident report submitted regarding alleged incident involving R1 and S1. Additionally, interviews with residents revealed that they have not witnessed any facility staff become physical with any resident. Nor have they heard another resident complain about being mistreated by staff. Based on interviews and documentation gathered, it has been determined that the Department does not have sufficient information to determine that the staff hit the resident; therefore, the allegation “staff hit resident while in care” is deemed Unsubstantiated at this time. It was further alleged that residents are not afforded privacy while in care due to staff coming into residents’ room without notifying the residents and recording the residents. Interviews with residents revealed that they are able to lock their doors at any time and staff knocks on the resident’s door before entering at any time. Furthermore, staff only come into residents’ room when they are conducting wellness checks throughout the facility or when doing housekeeping. When asked if they felt they had enough privacy while in their rooms, interviews with residents revealed that they feel they have privacy while in their rooms and, no one has ever recorded them without their consent. Interviews with staff revealed that the protocol for entering a resident’s bedroom at any time is knocking first, wait for a few seconds for a response, and then walk in. Based on interviews and the information obtained, it has been determined that the Department does not have sufficient information to determine residents are not afforded privacy. Therefore, the above allegation “Resident is not afforded privacy while in care” is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued. Copy of report sent via email.the state’s words, verbatim · CDSS document, Oct 19, 2021 · control 29-AS-20200615143142

Allegation investigated: Staff denied residents phone calls Staff did not provide resident with his mail

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to gather more information related to the investigation of the allegations above. LPA conducted previous visits to investigate the allegations above and a finding of Unsubstantiated was rendered but after further review more information was needed to complete the investigation into the allegations above. LPA met with facility staff and explained the reason for this visit. Regarding the allegations above it is alleged that staff have denied residents phone calls and was not providing residents with their mail. From approximately 9:45-10:15am, LPA conducted interviews with random residents regarding both of these allegations. During the visit LPA witnessed mail being placed in resident's mailboxes. Based on the information obtained through interviews and observation both allegations are still Unsubstantiated. Nothe state’s words, verbatim · CDSS document, Sep 15, 2021 · control 31-AS-20200124103238

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.