197608505-8-31-2022-28-AS-RORN-CT3RD6-20230623125523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 08/31/2022
Date Signed: 08/31/2022 12:43:17 PM

Unsubstantiated

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
11/05/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211105080603

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: 59	DATE:	08/31/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Narine Mertkhanyan; Executive Director		TIME COMPLETED:	12:58 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff changed resident medication without consulting with authorized representative.
Unlawful eviction.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced subsequent complaint visit regarding the above stated allegations. LPA met with Narine Mertkhanyan and explained the reason for the visit.

The investigation consisted of the following: during the initial visit conducted on 11/09/21, LPA interviewed the former Administrator and obtained copies of Staff & Resident Rosters. During today’s visit, LPA obtained copies from R1's file such as Physician's Report, Resident Appraisal, Resident Re-Appraisal, Identification & Emergency Sheet, and MARS from July 2021 - November 2021. LPA also interviewed the current Administrator and Staff #1 - Staff #2. R1 could not be interviewed as R1 is no longer a resident of the facility.

The investigation revealed the following: in regards to the allegation “staff changed resident medication without consulting with authorized representative”, it is alleged that facility staff changed R1’s medications without contacting her doctor or authorized representative. Interviews conducted with staff members denied the allegation. Staff interviewed indicated they will not make any changes to any residents medications without written Physician's Orders. Staff members interviewed indicated residents authorized representatives are notified of any resident changes. (CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
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)

Page: 1 of 2

Control Number 28-AS-20211105080603

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

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
26
27
28
29
30
31
32

Review of R1’s file revealed that facility staff were following R1's Physician's Orders. Any changes that were made to R1's medications were made following Physician's Orders. Staff members interviewed indicated medication is dispensed to residents by following Physician's Orders. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation “unlawful eviction”, it is alleged that on 10/25/21 R1 received an eviction notice alleging needing a higher level of care. LPA reviewed Eviction Notice dated 10/25/21 and determined Eviction Notice meets the Eviction Procedures per Title 22 Regulations. R1’s Physician determined that R1 requires a higher level of care due to multiple falls at the facility that have led to lacerations and trauma. Facility documented all of R1’s falls and hospitalizations as required. R1’s last physical day at the facility was on 11/05/21. R1 was transported to the hospital and did not return to the facility. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
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)

Page: 2 of 2