197608505-2-15-2022-28-AS-BTAO-CBP3RC-20220215172830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608505
Report Date: 02/15/2022
Date Signed: 02/15/2022 05:29:22 PM

Document Has Been Signed on 02/15/2022 05:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 64	DATE:	02/15/2022
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Brenda Chacon, Administrator		TIME COMPLETED:	11:00 AM

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Licensing Program Analysts (LPAs) Bonnie Tao and Ashley Calderon; Licensing Program Manager (LPM) Fernando Fierros conducted an informal meeting via virtual visit with Facility Administrator, Brenda Chacon, in attendance was LA County Public Health Nurse, Stacey Crosby. The purpose of the visit was discussed and was to ensure that the facility remains in compliance with DPH requests to obtain the resident and staff COVID 19 Line List and COVID 19 testing data.

During the Informal Conference, administrator stated the facility has a census of 64 residents and 27 staff. As of 12/30/21, since the start of the outbreak, the total # of number of COVID positive residents is 9 and COVID positive staff is 2. Administrator reported that Mass Testing was completed on 02/08/22 and a second round of mass testing is schedule for today, 02/15/22. Administrator reported sufficient staffing and requested some PPEs. Per DPH, a technical assistant visit is not needed at this time, as the facility has been in compliance with mitigation measures during last public health visit on 01/06/22.

During the virtual meeting, (DPH) discussed with Administrator, the importance of submitting the Facility's Line List in a timely manner upon DPH’s request. Administrator stated she will provide the Line List with COVID testing data to (DPH) and Licensing on a weekly basis until the outbreak is cleared.

(-continued in LIC 809 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/15/2022

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Administrator was advised that the Line List should contain all COVID tests results for staff and residents that tested, including positive and negative results. Administrator will provide the updated Line List to DPH and Licensing by 9AM on 02/16/22.

During Informal Conference, administrator was advised by licensing, that if the licensee does not comply with DPH requests for information regarding the COVID outbreak, the department may issue citations to the licensee.

No citations were issued during today’s Informal Conference. This licensing report was provided to Administrator for signature via email.

Exit interview conducted with Administrator Brenda Chacon.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC809 (FAS) - (06/04)

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