197608505-6-9-2022-28-AS-ACAN-CF8RMZ-20220609130935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608505
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:09:46 PM

Document Has Been Signed on 06/09/2022 01:09 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: 69	DATE:	06/09/2022
TYPE OF VISIT:	Case Management - COVID-19	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Quality Assurance : Rafaiel Silva		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 10:00 am Licensing Program Analyst (LPA) Ashley Calderon conducted a TA Visit at the facility . Assisting with the visit was facility staff Quality Assurance Rafaiel Silva, DPH Nurse Myra Valencia , and Doctor Lamis Al-Ahmed attended via zoom. Staff Census: 31 / Resident Census (All Memory Care) : 69 Total residents with covid-19: 30 in-house isolated and positive and 4 hospitalized . No Deaths Total staff with Covid: 8 staff , quarantining at home . Staff Coverage is covered no shortage of staffing. Mass Testing: Last Mass Testing Tuesday 6/7/22 and mass testing will continue once a week on Tuesdays. DPH Nurse recommendation do not re test covid positive residents as they were doing. Using Ashley's Clinical Diagnostic Lab for covid testing. Facility Visitor policy: None at this time. DPH Nurse and Doctor recommended that green and yellow zones are allowed visitors as long as they are following guidelines , wearing appropriate ppe and must have a negative test result. Absolutely no red zone visitors. Kitchen/ Meals: Clients eat in their rooms, caregivers distribute food to rooms , non communicable dining. Carts are being disinfected and they have posters in the kitchen on hand washing signs. Screening: Being done since the start of the pandemic. Staff are screened upon entry before starting their shift. Residents temperatures are logged 2-3 times a day.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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: 06/09/2022

NARRATIVE

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Staff training on infection control: Staff had trained on infection control , training done on 6/1/22.

Laundry
Staff do the laundry for the residents , they do yellow zone first and after red zone .

Hallways / Room Doors :
Have signs on isolated rooms , ppe sign outside of door as well as trash can placed inside has a lid and ppe stations outside of doors.

Break room:
Have disinfecting sign , maximum capacity sign on the door.

DPH Nurse Recommendations :
-Break room should have disinfecting wipes at all times and have break room rules for social distancing and disinfecting equipment's signs must be posted. Designate different break rooms for yellow and red zone staff.
-Kitchen should have maximum capacity sign on the door and hand washing signs posted.
-Hallways need hand sanitizer hand rubbing instruction sign.
-DPH provided resident room doors to have respiratory precaution signs for both yellow and red zones .
-Yellow zone rooms need ppe before entering.
-Docing signs inside of the residents room
-Designate staff for yellow and red zone . Rafaiel will have a list and designate staff for areas today 6/9/22 in the afternoon.
-Have a log to keep track on how often staff are cleaning and disinfecting.

LPA observed multiple signs posted around the facility as well as sanitation stations but need more signs provided by DPH. PPE supply was observed and they have sufficient amount. Silva stated that they have 4 unvaccinated residents, 1 staff religious exemption the rest vaccinated, 10 residents who are wanders will be transferred to a skilled nursing Norwalk Meadows, 4 residents are hospitalized at Glendale Memorial Hospital and Glendale Adventist Hospital. Line list will be provide updated today and faxed to LPA.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC809 (FAS) - (06/04)

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