Inspection Reports for Glen Terra

The inspection was an unannounced required one-year visit to evaluate compliance with licensing requirements at the Glen Terra Assisted Living Facility.

The facility was found to be in compliance with all applicable regulations, with no deficiencies observed during the visit. The facility was clean, well-maintained, and properly staffed, with functional safety and emergency systems.

The inspection was an unannounced case management visit conducted in conjunction with a complaint control #31-AS-20250314081909 to investigate compliance with licensing requirements.

The facility failed to update the Appraisal Needs and Services Plan for resident R1 despite changes in condition and did not submit a timely incident report regarding R1's hospitalization on 03/11/2025. Deficiencies were cited related to these failures.

The visit was conducted in conjunction with a complaint control #31-AS-20250314081909. The complaint involved failure to update resident R1's medical appraisal and failure to submit an incident report for R1's hospitalization. The Executive Director admitted no incident report was submitted. The complaint was substantiated by these findings.

An unannounced complaint investigation visit was conducted to investigate an allegation that staff did not ensure the facility was free from pests, specifically cockroaches seen on the third-floor hallway.

The investigation found no observable cockroaches during the physical plant tour, and interviews with staff and residents revealed insufficient evidence to verify the allegation. The complaint was determined to be unsubstantiated with no health and safety hazards noted.

The complaint alleged that cockroaches were present in the facility, specifically on the third-floor hallway. The allegation was unsubstantiated based on observations, record review, and interviews.

An unannounced complaint investigation visit was conducted in response to allegations that staff did not prevent a resident from developing a pressure injury, did not ensure adequate incontinence care, and allowed a resident to sleep in a wheelchair overnight.

The investigation found no sufficient evidence to support any of the allegations. Interviews and record reviews confirmed that the resident did not have a pressure injury, incontinence care was provided appropriately, and residents were not allowed to sleep in wheelchairs overnight. All allegations were unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included failure to prevent pressure injury, inadequate incontinence care, and allowing a resident to sleep in a wheelchair overnight. Interviews and records did not support these allegations.

An unannounced annual inspection visit was conducted by Licensing Program Analyst Rosaura Valenzuela to evaluate the facility's compliance with licensing requirements.

The facility was found to be clean, odor-free, and well-maintained with operational safety equipment including fire alarms, smoke detectors, and fire extinguishers. Bathrooms were clean with proper grab bars, and hot water temperature was within acceptable limits. Seven days of food supply and three first aid kits were observed. No deficiencies were issued at this time.

The visit was an unannounced complaint investigation conducted to investigate allegations that staff were not meeting residents' diapering needs and were not responding to residents' call buttons in a timely manner.

The investigation found that staff were regularly changing residents' diapers 3-4 times a day and responding to call buttons within 3 to 15 minutes. Based on interviews with residents and staff, the allegations were deemed unsubstantiated.

The complaint alleged that Resident #1 was left in soiled diapers for 1-2 hours and that staff took 45 minutes to an hour to respond to call buttons. Interviews with residents and staff revealed timely diaper changes and call button responses within 10 to 15 minutes. The complaint was unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate an allegation that staff did not ensure the facility was free from pests.

The investigation found no evidence of pests during the physical plant tour, staff interviews, or resident interviews. The facility has a contracted pest control company that treats the facility monthly. The allegation was deemed unsubstantiated.

The complaint alleged that staff did not ensure the facility was free from pests, specifically roaches seen in the kitchen cabinet and bathrooms. The allegation was unsubstantiated based on observations and interviews.

An unannounced complaint investigation visit was conducted in response to an allegation that staff were not providing basic care to a resident.

The investigation found that Resident #1 was well taken care of, receiving Hospice services, and was stable after treatment for diarrhea. The allegation was unsubstantiated with no health and safety issues noted at the time of the visit.

The complaint alleged that staff were not providing basic care to a resident. After interviews, records review, and observation, the allegation was found to be unsubstantiated.

An unannounced complaint investigation was conducted in response to allegations that staff do not ensure infection control plans are followed and that residents' personal property is not adequately disinfected.

The investigation found no sufficient evidence to substantiate the allegations. Residents suspected of having scabies were not medically diagnosed with it, and laundry practices were found to include washing residents' clothes separately with hot water and bleach for linens and towels, with no active scabies cases in the facility.

The complaint was unsubstantiated based on interviews and record reviews. Allegations included failure to follow infection control plans and inadequate disinfection of residents' personal property, both found unsupported by evidence.

The inspection visit was an unannounced required 1-year annual inspection to evaluate compliance with licensing regulations at Glen Terra Assisted Living Facility.

The facility was found to be clean, odor-free, and in good working order with proper bedding, furniture, and safety equipment. No deficiencies were issued during this inspection.

The visit was an unannounced complaint investigation conducted in response to an allegation that a resident was not adequately supervised.

The investigation found no sufficient evidence to substantiate the allegation. Staff and residents interviewed denied the claim, and the Licensing Program Analyst observed that the resident did not require one-on-one supervision but was regularly visited and assisted by staff.

The allegation was that a resident was not adequately supervised. Five staff members and seven residents interviewed denied the allegation. The resident's Needs and Services plan did not indicate a need for one-on-one supervision. The allegation was determined to be unsubstantiated due to lack of evidence.

The inspection visit was conducted as a complaint investigation following a complaint received on 05/04/2021 regarding allegations of inadequate record keeping and unexplained injuries sustained by a resident while in care.

The investigation substantiated the allegation of inadequate record keeping due to the facility's failure to retain the file of a discharged resident beyond the required three years. The allegation of unexplained injuries sustained by the resident was unsubstantiated based on staff interviews, resident interviews, and hospice agency notes.

The complaint investigation was substantiated for the allegation that the facility had inadequate record keeping, specifically the missing file for resident R1. The allegation that the resident sustained unexplained injuries while in care was unsubstantiated.

The visit was an unannounced complaint investigation triggered by allegations that a resident sustained multiple injuries while in care and that areas of potential hazard to residents with poor eyesight were not kept inaccessible.

The investigation found insufficient evidence to substantiate the allegations. Staff and residents denied the claims, and documentation reviewed did not corroborate the alleged injuries or hazards. Therefore, the allegations were determined to be unsubstantiated.

The complaint involved two allegations: 1) Resident sustained multiple injuries while in care, including falls resulting in a cut lip and possible shoulder injury; 2) Areas of potential hazard were not kept inaccessible, specifically a construction zone near the elevator. Interviews with staff and residents, file reviews, and observations did not provide enough evidence to substantiate either allegation. The complaint was deemed unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-03-28 regarding a resident sustaining a fracture while in care.

The investigation found that Resident #1 had multiple falls from September 2020 to March 2022 resulting in serious injuries including fractures. The facility failed to take action to mitigate the falls despite safety measures and recommendations for one-on-one care. The allegation was substantiated and a civil penalty was issued.

The complaint was substantiated. Resident #1 sustained multiple fractures due to falls while in care. The facility failed to provide required one-on-one care and did not take action after incidents. An immediate civil penalty of $500 was issued, with an enhanced civil penalty determination pending.

An unannounced complaint investigation was conducted following allegations that staff did not safeguard a resident's personal belongings and that staff financially abused a resident.

The investigation found no substantiation for either allegation. It was determined that the alleged staff member was a private caregiver, not facility staff, and the resident's purse was found. Financial withdrawals were payments to private caregivers, and the resident was confused due to hospitalization.

The complaint involved allegations that staff did not safeguard a resident's personal belongings and financially abused the resident. Both allegations were deemed unsubstantiated based on interviews and record reviews.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident sustained a fracture while in care.

The investigation found that Resident 1 had multiple falls from September 2020 to March 2022 resulting in serious injuries including fractures. The facility failed to take action to mitigate the falls or update the resident's care plan, despite a doctor's recommendation for one-on-one care. The allegation was substantiated and a civil penalty was issued.

The complaint was substantiated. Resident 1 sustained multiple fractures due to falls while in care. The facility failed to provide required one-on-one care and did not take corrective actions after incidents. An immediate civil penalty of $500 was issued, with an enhanced civil penalty determination pending.

The inspection was conducted as a complaint investigation following allegations received on 09/04/2020 regarding the facility's dietary services, food quality, variety of foods, timeliness of medical attention, and staff training.

The investigation found insufficient evidence to substantiate the allegations. The facility provided meals prepared with low sodium, used fresh and good quality ingredients, offered a variety of food choices, responded promptly to medical emergencies, and had adequately trained kitchen staff.

The complaint included allegations that the facility did not meet the resident's dietary needs, food was of poor quality, lacked variety, did not seek medical attention timely, and staff were inadequately trained. After investigation, these allegations were unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-01-17 regarding neglect, inadequate care, and insufficient staffing at Glen Terra Assisted Living Facility.

The investigation found no substantiated evidence to support the allegations of neglect, residents being left soiled, inadequate care and supervision, or insufficient staffing. Interviews with staff and residents, record reviews, and observations indicated that care and staffing levels met facility standards.

The complaint alleged that residents developed pressure injuries due to neglect, were left soiled for extended periods, were not provided appropriate care and supervision, and that the facility had insufficient staffing. The investigation found these allegations unsubstantiated based on interviews with staff and residents, record reviews, and observations.

The visit was conducted in response to a complaint alleging that a resident was left unattended, facility staff did not accompany the resident to the hospital, and the facility interfered with the resident's medical care.

The investigation found that the resident has lived at the facility since October 2021 and experienced a fall in August 2022. The resident refuses staff assistance on medical appointments. The facility staff denied interfering with medical care and now ensures accompaniment on appointments. The allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint involved allegations that a resident was left unattended, staff did not accompany the resident to the hospital, and the facility interfered with the resident's medical care. The investigation was unsubstantiated.

The visit was a case management inspection conducted during a complaint investigation regarding the facility's failure to submit a special incident report following a resident's fall and hospitalization.

The facility staff did not submit a required special incident report for resident #1's fall on 08/09/2022 and subsequent hospitalization, resulting in a cited deficiency.

Complaint #28-AS-20221129161405 triggered the investigation. The deficiency was substantiated as the special incident report was not submitted.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was exposed to amphetamines while in care.

The investigation found insufficient evidence to substantiate the allegation. Interviews with the administrator, staff, resident, and family members revealed no knowledge of how amphetamines were found in the resident's system. The Glendale Police Department closed the case with no crime due to lack of evidence.

The complaint alleged that a resident was exposed to amphetamines while in care. The allegation was unsubstantiated after investigation, including interviews and review of medical and police reports.

Licensing Program Analyst Alberto Lopez conducted a continuation annual visit to review medication for residents and verify completion of plans of correction issued during the initial visit on 2022-08-11.

Medication for 8 residents was found in compliance, no deficiencies were identified during this visit, and plans of correction from the initial visit were verified as completed.

An unannounced annual visit focusing on the infection control domain was conducted to evaluate compliance with regulatory requirements.

The facility was generally clean and odor-free, but several deficiencies were noted including water temperatures below the required minimum in some rooms, spoiled and expired food items, and doors housing dumpsters being in disrepair.

An unannounced complaint investigation visit was conducted regarding an allegation that a resident's apartment smelled malodorous, specifically smelling like sewage and causing the resident to feel sick.

The investigation found that most residents did not experience malodorous smells inside their rooms or the facility. A faint sewage smell was detected outside near the alley but did not enter the building. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated. Interviews with residents and staff revealed some noticed a smell related to septic tank cleaning outside the building, but no malodorous smells were detected inside during the visit. The city had cleaned the sewage system, but heat may cause lingering odors. One resident was offered a room change but refused.

An unannounced complaint investigation visit was conducted to determine the validity of allegations that staff removed a resident's personal belongings without permission and that the facility did not communicate the removal to the responsible party.

The investigation found that the resident's power of attorney removed the electrical burner without notifying the facility, and the facility staff were not responsible for the removal. There was no preponderance of evidence to substantiate the allegations, so they were deemed unsubstantiated.

The complaint investigation was unsubstantiated as the evidence showed the resident's power of attorney removed the item without notifying the facility, and the facility was unaware of the removal.

An unannounced complaint investigation was conducted following a complaint received on 08/02/2021 regarding allegations that the facility did not provide adequate supervision to a resident and did not report a resident missing in a timely manner.

The investigation substantiated that the facility failed to provide adequate supervision, resulting in a resident leaving the facility unassisted. The allegation that the facility did not report the resident missing was unsubstantiated. Plans of correction were developed to address the supervision deficiency.

The complaint investigation was substantiated for inadequate supervision leading to a resident leaving the facility unassisted. The allegation regarding failure to report the resident missing was unsubstantiated.

The visit was an unannounced complaint investigation conducted in response to allegations that staff failed to meet residents' medical needs, were not allowing visitors, and failed to provide residents with a comfortable environment.

The investigation included interviews with staff and residents and review of documentation. None of the allegations were corroborated by the evidence gathered, and the complaints were determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included failure to meet resident's medical needs, denial of visitors, and failure to provide a comfortable environment. Interviews and observations did not support these allegations.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not preventing the spread of an outbreak.

The investigation found that staff were observed wearing masks and hand sanitizers were available throughout the facility. Although previous visits noted staff not wearing masks properly and residents not social distancing, these deficiencies were corrected by the time of this visit. The allegation was substantiated but no new deficiencies were cited.

The complaint alleged that staff failed to wear masks consistently and did not ensure residents were social distancing. The allegation was substantiated based on prior visits, but no deficiency was cited due to correction of previous deficiencies.

An initial complaint investigation was conducted by Licensing Program Analyst Christine Wong at the Glen Terra Assisted Living Facility, including a tour of the facility and measurement of hot water temperatures in residents' rooms.

The inspection found that hot water temperatures in rooms #111, #120, and #214 ranged between 122.6 and 124.7 degrees Fahrenheit, exceeding the regulatory maximum of 120 degrees, posing an immediate risk to residents. A citation was issued for this deficiency.

Initial complaint investigation conducted; deficiency substantiated with citation issued.

The visit was an unannounced complaint investigation conducted in response to an allegation that the facility was not reporting COVID-19 cases.

The investigation found that although some residents stated they were not informed about positive COVID-19 cases, the facility had reported the most recent case to Community Care Licensing on 2022-01-20. There was insufficient evidence to prove the alleged violation, so the complaint was unsubstantiated.

The complaint alleged the facility was not reporting COVID-19 cases. The investigation included interviews with the Administrator, staff, and residents, and review of documentation. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation conducted due to an allegation that the facility was not following COVID-19 outbreak guidance.

The investigation found that while staff were wearing masks correctly and social distancing was observed, the facility did not fulfill COVID-19 testing guidance as not all residents were tested as required after a confirmed COVID-19 case. The allegation was substantiated.

The complaint alleged the facility was not following COVID-19 outbreak guidance. The allegation was substantiated based on observations, interviews, and record review.

The inspection was an unannounced complaint investigation visit conducted in response to allegations that residents were being subjected to second-hand smoke, the facility had a pest infestation, and the facility was not notifying residents of bedbugs.

The investigation included interviews with staff, residents, and review of pest control records. The allegations were found to be unsubstantiated due to lack of preponderance of evidence, with residents and staff denying the presence of second-hand smoke exposure, pest infestation, or bedbugs.

The complaint investigation was unsubstantiated as the evidence did not prove the alleged violations occurred. Allegations included second-hand smoke exposure, pest infestation, and failure to notify residents of bedbugs.

An unannounced complaint investigation was conducted to investigate the allegation that a resident was smoking in their room where oxygen is in use.

The investigation found that although one resident had smoked in his room, there was no oxygen in that room and the facility has a designated smoking area. Staff and residents confirmed that smoking in rooms is not allowed and the facility is actively addressing the situation. There was insufficient evidence to substantiate the allegation.

The complaint alleged that a resident was smoking in their room where oxygen is in use. The allegation was found to be unsubstantiated due to insufficient evidence.

An unannounced complaint investigation visit was conducted to investigate allegations including illegal eviction threats, malfunctioning front door and elevators, untimely staff response to pendents, and inadequate food service.

The investigation involved interviews with residents, staff, and the administrator, as well as document reviews and observations. All allegations were found to be unsubstantiated based on the evidence gathered.

The complaint investigation was unsubstantiated. Allegations included staff threatening illegal eviction, front door and elevator malfunctions, delayed staff response to pendents, and inadequate food service. Interviews with residents and staff, observations, and document reviews did not support these allegations.

The visit was a case management visit regarding COVID-19 recommendations and guidelines conducted by Licensing Program Analyst Mary Flores.

The analyst observed that the receptionist was not wearing a face mask properly, posing an immediate personal rights, health, and safety risk to persons in care. Civil penalties were assessed for a repeat violation within 12 months.

An unannounced complaint investigation was conducted regarding an allegation that a resident's colostomy bag was not being regularly changed and had not been changed in 14 hours, causing it to start leaking.

The investigation included interviews with staff and residents, and review of resident records. It was found that the facility was providing assistance with colostomy bag changes according to physician orders and resident requests. The allegation was found to be unsubstantiated based on the preponderance of evidence.

The complaint alleged that a resident's colostomy bag was not being regularly changed and had not been changed in 14 hours, starting to leak. After investigation, including interviews and record review, the allegation was found unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the facility was not providing comfortable living accommodations to residents, specifically that residents with wheelchairs could not access the bathroom sinks.

The investigation included interviews with staff and residents, a tour of the facility, and observations. The allegation was found to be unsubstantiated as staff denied the allegation, residents could not corroborate it, and observations showed that residents in wheelchairs could access bathroom sinks independently.

The complaint was unsubstantiated based on interviews with 5 staff members and 6 residents, observations of residents using bathroom sinks, and review of facility conditions. The preponderance of evidence standard was not met to support the allegation.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 04/12/2021 alleging that facility staff did not safeguard a resident's personal property.

The investigation found that the resident or their responsible party refused to inventory personal belongings at admission, and interviews with residents and staff did not corroborate the allegation of theft. The allegation was found to be unsubstantiated based on observations, interviews, and document review.

The complaint alleged that facility resident #1’s personal property, including a wedding ring and stimulus card, was stolen. The allegation was unsubstantiated after investigation.

The visit was a plan of correction (POC) visit conducted to address deficiencies cited on 08/03/2021 and 08/10/2021, following an annual inspection and case management continuation visit focusing on infection control, medication, and food review.

Several type A deficiencies cited on 08/03/2021 and 08/10/2021 were cleared by 08/19/2021, including issues with social distancing during meals, staff wearing face coverings, and pest control in a bathroom. However, a deficiency related to ensuring an auditory system for residents with dementia was not cleared. Civil penalties totaling $800 were assessed for failure to correct this deficiency.

An unannounced complaint investigation was conducted regarding an allegation that a resident's colostomy bag was not being regularly changed.

The investigation included interviews with staff and residents, review of resident files and care plans, and observations. The evidence showed that the facility provided care consistent with physician orders and the allegation was found unsubstantiated.

The complaint alleged that the resident's colostomy bag was not changed timely and had not been changed in 14 hours, causing leakage. Interviews revealed mixed resident experiences with response times for assistance. Staff reported varying frequencies for changing colostomy bags, and documentation supported that care was provided as needed. The allegation was found unsubstantiated.

Licensing Program Analyst Mary Flores conducted a continuation annual visit to review medication for residents and overall facility compliance.

Medication was found in compliance; however, deficiencies were cited including lack of an auditory device to monitor dementia residents exiting the facility, presence of ants in room #219, and improper removal of empty oxygen tanks from room #322.

An unannounced annual visit was conducted focusing on the infection control domain and food supplies to assess compliance with health and safety regulations.

The facility was generally clean and well-maintained, but deficiencies were noted including lack of proper social distancing during residents' lunch, staff not wearing face coverings, and missing hand washing signs. Water temperatures in resident rooms were within recommended ranges. Additional deficiencies in other domains were observed but will be addressed in a future visit.

An unannounced complaint investigation was conducted following allegations that staff did not assist a resident with medication, toileting, and oxygen administration in a timely manner on 07/16/2021.

The investigation included interviews with staff and residents and review of relevant documents. There was insufficient evidence to substantiate the allegations, and no deficiencies were cited under California Code of Regulations Title 22.

The complaint involved allegations that staff delayed assistance with medication, toileting, and oxygen administration for a resident. Staff and most residents denied the allegations, and document reviews showed timely care. The allegations were unsubstantiated due to lack of preponderance of evidence.

An unannounced complaint investigation was conducted due to allegations of staff neglect resulting in a resident ingesting a foreign object and staff not seeking medical attention in a timely manner.

The investigation found no preponderance of evidence to prove the allegations; the resident was sent to the hospital timely and the ingestion of the foreign object could not be confirmed to have occurred at the facility. Therefore, the allegations were unsubstantiated and no deficiencies were cited.

The complaint investigation was unsubstantiated. Allegations included staff neglect causing a resident to ingest a foreign object and failure to seek timely medical attention. Interviews and records showed the resident was monitored, sent to the hospital on 2/12/21 after oxygen levels dropped, and the ingestion of the denture bracket was not confirmed to have occurred at the facility.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 2021-01-11 regarding allegations that the facility did not meet residents' needs for care and supervision, did not ensure operable oxygen equipment, and lacked an emergency disaster plan for power outages.

The investigation found that residents and staff reported adequate care and supervision, oxygen equipment was checked and operable during a brief power outage, and the facility had an updated emergency disaster plan with a standby generator and emergency lighting. There was insufficient evidence to substantiate the allegations, and all were deemed unsubstantiated.

The complaint investigation was unsubstantiated based on interviews with residents, staff, and review of facility documents and observations. Allegations included failure to meet care needs, non-operable oxygen equipment, and lack of emergency disaster plan for power outages, all found unsupported by evidence.