197608505-1-21-2021-28-AS-MVAO-BY3NX2-20210209095025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 01/20/2021
Date Signed: 01/21/2021 12:40:48 PM

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
08/24/2020 and conducted by Evaluator Renee Arterberry

COMPLAINT CONTROL NUMBER: 28-AS-20200824094825

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: 65	DATE:	01/20/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Nirjara Acharya, Administrator/Executive Director		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident developed pressure injuries due to neglect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ren’ee Arterberry initiated a Complaint Follow-Up Visit to continue the investigation of the allegation noted 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/Executive Director, Nirjara Acharya and the purpose for the call was discussed.

The investigation consisted of the following: on 09/02/20 at 9:35 AM the LPA interviewed the administrator and Service Coordinator who shall be referred to as, RC. The LPA requested and received the following documents: Admission Agreement, Physician Report. The Director supplied the requested documents and the following documents: Frank Laterman Regional Center Annual Review dated 03/12/2018, Southern California Hospital Prescription Order, Southern California Hospital Discharge Instructions, Glen Park at Glendale-Boynton Admission Agreement dated 05/10/2019, Frank Laterman Regional Center Individual Program Plan/IPP dated, 03/11/2016, Glendale Memorial Report dated 08/21/2020, Physician Report for Residential are Facilities for the Elderly (RCFE) dated 04/22/2019

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee Arterberry	TELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

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-20200824094825

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: 01/20/2021

NARRATIVE

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and Southern California Hospital Discharge Instructions dated 08/07/2020, Southern California Hospital at Hollywood prescription, Glendale Memorial Hospital Patient Visit Information, Glen Park Physicians Visits and Glen Park Admission Agreement.

The investigation reveal the following: a resident who shall be referred to as R1 was admitted to Glen Park at Glendale-Boynton St. on 05/10/2019 with no history of skin condition or breakdown. According to the Special Unusual Incident Report /SIR dated 07/30/2020, R1 was admitted to the hospital due to "peeling the skin off on right foot". R1 was returned to the facility a few hours later with dressing on her right foot. According to the SIR dated 08/14/2020 R1 was hospitalized due to " needed wound care for both feet". As noted on the hospital Discharge Instructions, R1 was diagnosed as "foot ulcer". As noted on the SIR dated 08/17/2020 R1 was admitted to the hospital and returned to the facility the same day. R1 was diagnosed with "ulcer of foot". On 08/23/2020 R1 was referred to Regal Medical Group to receive wound care on an outpatient bases. The administrator state that R1 is a diabetic and the skin condition on her feet are skin lesions and are not pressure injuries. A review of the Glendale Memorial Transfer Report dated 08/20/20 reveal that R1 was diagnosed with "excoriated skin to bottom of both feet". According to the prescription, R1 was prescribed, "ketoconazole 2 % topical cream". As noted on the Physician's Report dated 04/22/2019 R1 did not have a history of skin breakdown. On 08/24/20, R1 was transported to Glendale Memorial Hospital for abrasions of the left and right feet. Glendale Memorial Hospital Patient Visit Information note a referral: "discuss with primary physician in charge of patient for referral to see wound clinic or wound specialist".

Based on the medical documents provided, R1 was not diagnosed with, "pressure injuries". The skin condition observed on her feet was diagnosed by health care professionals as, "ulcer of feet". Based on the evidence, medical documents provided and interview conducted the finding is unsubstantiated.

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 complaint investigation of the allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

An exit Interview was conducted via telephone with the administrator and a hardcopy was provided via email for signature. Signatures on hardcopies.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee Arterberry	TELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

LIC9099 (FAS) - (06/04)

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