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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608505
Report Date: 06/16/2022
Date Signed: 06/16/2022 02:58:37 PM


Document Has Been Signed on 06/16/2022 02:58 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 STFACILITY NUMBER:
197608505
ADMINISTRATOR:PINK, JR, TILLMANFACILITY TYPE:
740
ADDRESS:1250 BOYNTON STTELEPHONE:
(818) 246-9000
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:98CENSUS: 66DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Staff Rafael SilvaTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Jose Villalobos, conducted a required annual inspection focused on Infection Control Domain using the Inspection Tool. LPA met with Staff Rafael Silva and the purpose of the visit was discussed.

As a part of the inspection, LPA reviewed client files, Staff files, client medications, and toured the physical plant. LPA conducted a review of (7) resident files and (7) staff files. LPA conducted a review of Medication Administration Record (MAR) and medications for (7) residents. All medications and records are maintained in compliance with label instructions. All records are maintained in order.

The facility is a single story building. Common areas, including the living room, activity room and dining room, all appeared clean and were properly furnished. The kitchen appeared clean and the appliances and fixtures functional. Entry/exits were free of obstruction. The medications were locked in the medication room, properly labeled and stored. Medication documentation and implementation appeared to be complete. Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Water temperature properly measured within Title 22 regulations. LPA observed perishable and non-perishable food supply. LPA tested facility Carbon Monoxide and Smoke Detectors and are working properly. Fire Extinguishers observed and fully charged. All disinfectants, cleaning solutions toxins and sharps were inaccessible to residents. Medications are centrally stored in locked cabinet inaccessible to residents. Facility first aid kit observed. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. The facility has a functional operating landline telephone in kitchen. Required postings observed. Infection control practices are being followed.



LPA did not observe deficiencies; therefore, no citations are issued. Inspection Tool was completed.
Exit interview was conducted, and a Facility Evaluation Report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
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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