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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608505
Report Date: 10/24/2022
Date Signed: 10/24/2022 05:05:31 PM


Document Has Been Signed on 10/24/2022 05:05 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: 60DATE:
10/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Narine Mertkhanyan TIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Angelica Rea and Kimberly Ramirez, during the course of investigating complaint #28-AS-20201026110759, requested to review resident #1's file. Administrator stated that they have resident #1's file, however they were unable to locate it at the time of the visit. Facility will be cited accordingly.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/24/2022 05:05 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
Section Cited

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Resident Records. Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by: Facility administrator was unable to locate resident #1's file during today's visit.

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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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2