197608505-8-31-2022-28-AS-MVAO-CJYS2H-20221007132933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 08/31/2022
Date Signed: 08/31/2022 12:02:52 PM

Substantiated

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
08/25/2022 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20220825113139

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: 61	DATE:	08/31/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Administrator Narine Mertkhanyan		TIME COMPLETED:	12:17 PM

ALLEGATION(S):

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Lack of supervision resulting in resident sustaining injury while in care

INVESTIGATION FINDINGS:

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On 8/31/22 at 10:15 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced subsequent complaint visit to investigate the allegation listed above. The initial complaint visit was conducted on 8/26/2022. Upon arrival, LPA met with Narine Mertkhanyan (Administrator) and explained the purpose of the visit.

During the initial visit, LPA toured the facility with the administrator and obtained the resident/ staff roster, R1 discharge paperwork dated 8/17/2022 and 8/21/2022, Facility incident report, photos of R1 bruising, R1 behavioral plan, R1 functional behavior assessment. LPA interviewed residents R2 through R7 and R1 is nonverbal. LPA Interviewed administrator and staff S1 and S2. LPA discovered S1 is no longer working with the facility.

Report continued on 9099c

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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-20220825113139

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: 08/31/2022

NARRATIVE

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Prior to the visit LPA received R1's IPP and 1:1 hours from Lanterman Regional Center Case Manager.

During today’s visit LPA reviewed camera footage of R1's fall on 8/17/22 and interviewed Staff S3.

The investigation reveals the following: Regarding " Lack of supervision resulting in resident injury while in care". It is alleged that R1 was injured while in the care of S1. During the interview, S1 stated that R1 had a fall two (2) days prior, and the bruising was old. LPA conducted file review and confirmed that R1 sustained a fall on 8/17/22. R1 was sent to the hospital for evaluation for the fall on 8/17/22 and the bruising on 8/19/22. The discharge paperwork dated 8/21/22 stated R1’s bruising is due to the fall dated 8/17/22. The administrator confirmed that R1 did not have a 1:1 at the time of the fall on 8/17/22. Administrator also stated that 1:1 staff called out, and it was hard finding replacement for R1. Lanterman Regional Center confirmed R1 1:1 hour is from 7 am- 11 pm. Special incident report date 8/17/22 stated R1 fell at 11:35 am. LPA reviewed the camera and confirmed no care staff was around R1 at the time of the fall.

Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.

Exit Interview Conducted with administrator Narine Mertkhanyan / Appeal Rights Provided / A Copy of the Report Issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220825113139

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: 08/31/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/01/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities ...All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...	1 2 3 4 5 6 7	Licensee will ensure that R1 has a 1:1 from 7 am- 11 pm and have adequate care and supervision to ensure R1 safety. Licensee will submit a plan on how they will ensure resident #1 will have a 1:1 if the assigned caregiver is not available. Plan to be submitted by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observations, interviews and file review the licensee did not comply with the section cited above bynot ensuring R1 has a 1:1 from 7am- 11 pm. This resulted in R1 sustaing an unwitness fall at 11:35 am, which poses an immediate health, safety, or Personal rights risk to 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: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

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