197608505-11-16-2021-28-AS-MVAO-CAMQ7N-20220113105525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 11/16/2021
Date Signed: 11/16/2021 01:38:04 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
09/01/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20210901142100

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: 63	DATE:	11/16/2021
		UNANNOUNCED	TIME BEGAN:	12:48 PM
MET WITH:	Nirjara Acharya - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility is not following COVID-19 public health orders for visitation.

INVESTIGATION FINDINGS:

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This report supersides report on 9/7/21 to change finding for allegation: facility is not following COVID - 19 publich health orders for visitation to substantiated.
On 9/7/21 Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Brenda Chacon assistant administrator and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested staff/resident roster, a copy of the mitigation plan, visitation policy, copy of email notification to family members, visitors log for 1 month, cleaning and disinfecting log for 1 month, and training on COVID cleaning and disinfecting. LPA Flores interviewed Resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6) and Staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5),#6(S6).

The investigation revealed the following: Regarding allegation: Facility is not following COVID- 19 public health orders for visitation. It is alleged facility's "visitation guidelines" recently implemented at the facility are in violation of current official guidelines. (CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 28-AS-20210901142100

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: 11/16/2021

NARRATIVE

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Interviews with residents 2 out of 6 residents stated to not have visitors. 1 out of 6 residents stated to receive visitors and to have additional visitation sources like video call and 3 out of 6 were not able to answer due to cognitive skills. Interviews with staff 4 out of 6 staff stated facility has a visitation plan which requires visitors to have a negative COVID test and visitors have additional visitation options and 2 out of 6 staff were not aware of visitation guidelines. LPA Flores reviewed visitation guidelines emailed to administrator on August 23, 2021 by corporate office and forward to resident representatives on the same day. Visitation guidelines state visitation hours which must be schedule ahead, "required to be tested on their own prior to coming to the facility (within the last 2-3 days) with proof of negative test results and date of the test... Visitors who are unable to adhere to the core principles of COVID 19 infection prevention should not be permitted to visit or should be asked to leave...If it is not possible to have outdoor visitation then visitation will take place in a designated space that has room for physical distancing and adequate ventilation, if available." Administrator Nirjara Acharya stated facility provides a COVID rapid test for family members that may not have a test upon arriving or are not aware of policy, families are able to take residents out or have outdoor visit if not able to provide a negative COVID test result, and facility offers other visiting options such as window visits, video call, and/or phone calls. LPA reviewed visitation log for 7/31/21 to 9/1/21. Per PIN 21.17.2 ASC dated 5/14/21 Licensees should allow indoor visitation, including in-room visitation, at all times and for all residents, regardless of vaccination status of the resident or visitor. During the visit of 9/27/21 LPA Flores discussed current PIN 21.40ASC with new visitation guidelines.

Based on LPA's observations, documents review, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Nirjara Acharya Administrator and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
09/01/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20210901142100

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: 63	DATE:	11/16/2021
		UNANNOUNCED	TIME BEGAN:	12:48 PM
MET WITH:	Nirjara Acharya - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility is not properly disinfecting facility surfaces.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20210901142100

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: 11/16/2021

NARRATIVE

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Regarding allegation: Facility is not properly disinfecting facility surfaces. It is alleged visitation room it is only cleaned once a day, not after each visit. Interviews with residents 1 out of 6 residents stated visitors room gets cleaned after each visit, 5 out of 6 resident were unable to answer due to cognitive skills. Interviews with staff 4 out of 6 staff stated visitation room gets cleaned and disinfected after each visit and 1 out of 6 staff stated to not know be aware of cleaning and disinfecting of visitation room. LPA reviewed staff training dated 6/24/21 employee guidelines and mitigation plan dated 1/22/21 states "Clean and disinfect frequently touch objects visitors may use or could have used including ... rooms after each meeting between a visitor and person in care." LPA Flores observed assistant administrator disinfect the visitation area in which interviews were conducted upon entering the room, no trash or unattended items were observed.

Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been
met, therefore the above allegation(s) are found UNSUBSTANTIATED.

Exit interview was conducted with Nirjara Acharya Administrator and copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20210901142100

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/17/2021 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	87468.1 Personal Rights for all Residents:(a)Residents... shall have all...personal rights: To have their visitors, ... permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon This requirement is not met as evidency by:	1 2 3 4 5 6 7	Administrator updated family's and responsible parties regarding visitation guidelines via phone call and email, which will be following PIN 21.40ASC as of 9/17/21. Deficiency cleared on 11/16/21.
	8 9 10 11 12 13 14	Based on document review and interviews conducted licensee did not provided visitation at all times for residents in care which poses a health, safety, or personal rights risk for the persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC9099 (FAS) - (06/04)

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