197608505-5-4-2023-28-AS-TVAO-CRVSYB-20230516141714

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 05/04/2023
Date Signed: 05/04/2023 01:42:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/11/2021 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210611091608

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: 65	DATE:	05/04/2023
		UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Brenda Chacon/S-4		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Personal Rights: Resident sustained serious fall resulting in death.
Personal Rights: Resident sustained unexplained bruising while in care.
Personal Rights: Resident lost significant amount of weight while in care.
Personal Rights: Resident's care needs were not met while in care.
Personal Rights: Facility denied access to Ombudsman.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit pertaining to the above allegations. LPA met with Brenda Chacon (S-4) and explained the purpose of today’s visit.

The initial/health and safety visit was conducted on 06/11/2021 by Licensing Program Analysts (LPAs) Christine Wong and Alberto Lopez. LPA's met with Administrator, Nirjara Acharya and Assistant Administrator Brenda Chacon who assisted with the tour. During this visit, LPAs did not observe any signs of neglect, abuse or other immediate health and safety threats. LPAs also obtained documentation for Resident #1(R-1) through Resident #3 (R-3).

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: 323-981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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-20210611091608

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST	FACILITY NUMBER: 197608505
	VISIT DATE: 05/04/2023

NARRATIVE

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Department of Social Services -Community Care Licensing Division (DSS/CCLD) Investigator Laura Garcia conducted the following: interviewed R-1’s authorized representative, obtained Coroner’s Report, obtained a copy of Glendale Police Department incident report, obtained medical records, interviewed Facility Executive Director, Interview Staff #1 (S-1) through Staff #6 (S-6) and interviewed R-1’s hospice agency.

Allegation : Resident sustained serious fall resulting in death. Per Investigator Garcia’s interviews and documentation obtained “there was insufficient evidence to determine if there was neglect/lack of supervision on behalf of facility members which lead to the death” of R-1. Per Investigator Garcia’s investigation, the cause of death noted on R-1’s death certificate was not due to a fall. Per Investigator Garcia, R-1 passed away on 05/04/2021 while residing at another facility. Per documentation reviewed, R-1 was discharged/moved out from this facility on 03/24/2021. Interviews conducted and documentation obtained do not corroborate this allegation.

Allegation: Resident sustained unexplained bruising while in care. Per Investigator Garcia’s interviews and documentation obtained, (S-6) “denied ever hurting” R-1 or “striking” R-1. Glendale Police Department conducted interviews and “was unable to determine if a crime had occurred”. Interviews revealed that R-1 was aggressive and was known to display self injurious behaviors. Hospice documented that R-1 also bumped self with furniture which may have contributed to unexplained bruising. Interviews revealed that R-1’s authorized representative was aware of R-1’s behaviors. Staff interviews revealed that staff had not witnessed any staff physically abusing R-1. Staff interviews revealed that they did not receive any concerns/complaints in regards to R-1. Interviews conducted and documentation obtained do not corroborate this allegation.

Allegation: Resident lost significant amount of weight while in care. Hospice documentation indicate that R-1 preferred to sleep and skip meals due to the “grogginess” of the medications which was communicated to R-1’s authorized representative. Per S-4, staff document residents’ weight on a monthly basis. LPA obtained weight records for R-1 from December 2020 (Admission) through March 2021 (Discharge). Upon discharge/move out date (03/24/21), R-1 had a weight difference of (4) pounds. Per interviews conducted, staff and hospice agency were in constant contact with R-1’s authorized representative about R-1’s health and needs. Interviews conducted and documentation obtained do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: 323-981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210611091608

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST	FACILITY NUMBER: 197608505
	VISIT DATE: 05/04/2023

NARRATIVE

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Allegation : Resident's care needs were not met while in care. It is alleged that this facility staff was not providing R-1 with care needs while in care. Based on reviewed documents and interviews conducted, the facility staff informed R-1’s authorized representative and hospice agency of R-1’s change in condition. The facility staff also submitted special incident reports for R-1 to Community Care Licensing. Interviews conducted and documentation obtained do not corroborate this allegation.

Allegation: Facility denied access to Ombudsman. It is alleged that the facility denied access to Ombudsman. LPA attempted to have contact with Ombudsman and was unable to reach a representative. Per S-4, staff do not deny access to Ombudsman. Per S-4, Ombudsman staff come in and request a copy of the resident roster (proper identification is reviewed/confirmed) prior to releasing a copy of the resident roster. Per S-4 once this step is completed, Ombudsman visits the residents in their room privately. Per S-4, S-4 has not received any requests for resident records nor recalls any Ombudsman representative visiting R-1. Interview does not corroborate this allegation.

Based on record review and interviews conducted the findings indicate, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED.

An exit interview conducted, appeal rights and a copy of this report was provided to Brenda Chacon.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: 323-981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

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