197608505-12-19-2020-28-AS-MVAO-BXVNDG-20210203092216

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 12/17/2020
Date Signed: 12/19/2020 06:06:50 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2020 and conducted by Evaluator Christine Wong

COMPLAINT CONTROL NUMBER: 28-AS-20200811143238

FACILITY NAME:	GLEN PARK AT GLENDALE - BOYNTON ST		FACILITY NUMBER:	197608505
ADMINISTRATOR:	PINK, JR, TILLMAN		FACILITY TYPE:	740
ADDRESS:	1250 BOYNTON ST		TELEPHONE:	(818) 246-9000
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	98	CENSUS: 66	DATE:	12/17/2020
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Administrator Nirjara Acharya		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff neglect resulted in resident getting infected.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint investigation to deliver findings on the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Nirjara Acharya

The investigation consisted of the following: the initial complaint visit was conducted on 8/18/20. LPA Wong requested documents pertaining to resident (R1) and staff and resident roster. LPA also interviewed the administrator and office manager. In addition, LPA interviewed 9 residents on 09/30/20 and additional 8 staff on 11/06/2020.

The investigation revealed of the following: Allegation “Staff neglect result in resident getting infected.” All residents and staff denied the allegation. All residents reported they feel safe living in the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020

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-20200811143238

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 PARK AT GLENDALE - BOYNTON ST	FACILITY NUMBER: 197608505
	VISIT DATE: 12/17/2020

NARRATIVE

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During this pandemic, all the staff would wear mask in the facility but not all residents would wear mask, the staff would keep reminding residents to put on a mask. Besides wearing mask, staff would constantly be reminding the residents to wash hands and practice social distancing too. Per administrator, the facility has been started checking resident’s temperature three times a day, teaching residents how to wash their hands, wearing mask, practicing social distancing and no visitors were allowed in the facility since March 2020. In addition, any residents go out from the facility, they must have to wear mask and check temperature when they return. All staff reported R1 would never put on a mask and R1 would take the mask off immediately if staff assists her to put on. Sometimes R1 would even being agitated to the staff when staff instructed her to do. R1 also needs to be reminding constantly for washing hands as R1 was always confused due to her medical diagnosis.
Based on statements and interviews conducted with staff and residents and there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

A telephonic exit interview was conducted with Administrator Nirjara Acharya. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020

LIC9099 (FAS) - (06/04)

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