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Complaint Investigation Report

Glen Park at Valley Village, Valley Village02/10/2023Licence 197603165

Census57
Date signed02/10/2023 01:01:51 PM
The inspector’s account

On 02/07/2023, LPA Urena conducted a facility folder review in the CCLD Server system to locate the Unusual Incident/Injury Report (LIC 624) pertaining to R1’s hospitalization on 10/23/2020, and to review the section ‘ AGENCIES/INDIVIDUALS NOTIFIED’ . The results were negative, as the LPA after an extensive search, could not locate a report pertaining to the hospitalization of R1, consequently the CCLD office didn't receive an Incident Report. However, LPA Urena did locate a Death Report (LIC 624A) dated 10/29/2020, and submitted by S1 to CCLD via fax; which describes that the Social Worker for the SNF contacted Glen Park at the Valley Village on 10/28/2020, and spoke with the med tech to inform them of the passing of R1, and to request the name of the family's member phone number to notify the family. Additionally, LPA Urena conducted a file review of R1’s documents emailed by the facility to LPA Basili. The record review revealed that the emergency information form (LIC 601) listed the next of kin, and name of nearest relative of R1. On 02/10/2023, at 10:20 a.m., LPA Urena interviewed S1, and requested all LIC’s 624 related to R1 during their stay at the facility. The interview revealed that according to S1's recollection, the family was informed about R1 going to the hospital. Staff was unable to provide file for R1, due to not having a relief staff, and documents not being within reach.

Based on the information obtained, and record review, there is sufficient evidence to substantiate the allegation that the facility did not inform the family members, and the CCLD about R1 being hospitalized on 10/23/2020. Therefore, the allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-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.

Citations were issued. Exit interview conducted. A copy of the report and appeal rights were provided.

Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction