197608505-10-11-2023-28-AS-RORN-CWJRVL-20231012132142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 10/11/2023
Date Signed: 10/11/2023 01:29:29 PM

Substantiated

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
01/26/2021 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210126124057

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: 64	DATE:	10/11/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Brenda Chacon		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident sustained multiple burns while in care

INVESTIGATION FINDINGS:

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This is a subsequent visit to previous visit conducted on 3/9/23, with additional deficiencies added to the 9099-D.

Licensing Program Analyst (LPA) Angelica Rea met with Office Manager, Brenda Chacon, who assisted with today's visit.

Regarding the allegation that Resident #1 sustained multiple burns while in care, the investigation was conducted by the department, which included interviews with staff, residents, and review of resident #1's facility file and hospital records.

The investigation revealed that on 1/23/21, resident #1 was found by staff #1, in the bathtub with hot water running. Resident #1 was sent to hospital. It was determined that resident #1 was scalded by hot water and suffered multiple first and second degree burns to the face and body.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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-20210126124057

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: 10/11/2023

NARRATIVE

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Review of resident #1's file, including needs and services plan dated 6/19/20, indicates that resident #1 had severe cognitive impairment, and a history of wandering throughout the facility. Per documentation and interviews, Resident #1 was often disoriented and confused, and required assistance with completing all activities of daily living.

Staff interviewed stated that resident #1 needed a higher level of care, and/or one to one supervision.

Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

An immediate $500 civil penalty was previously issued.

The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e)or (f).

Exit interview conducted. Appeal rights explained.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20210126124057

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/18/2023 Section Cited CCR 87705(b)(2)	1 2 3 4 5 6 7	(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.	1 2 3 4 5 6 7	LIcensee shall follow Title 22 regulations and ensure that the facilty's plan of operation is followed, and the needs to address residents with dementia are followed to ensure the safety of residents in care. Licensee to conduct staff in service on this regulation, and will submit proof of training to LPA by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Staff interviewed stated that resident #1 had severe cognitive impairment and a history of wandering. The facility did not provide safety measures to address resident #1's wandering behavior, which resulted in resident #1 sustaining multiple 1st and 2nd degree burns.	8 9 10 11 12 13 14
Type A 10/18/2023 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.	1 2 3 4 5 6 7	Licensee shall follow Title 22 regulations and ensure that residents with dementia have the adequate number of direct care staff to support their needs. LIcensee to conduct staff inservice on this regulation and will submit proof of training to LPA by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Staff interviewed stated that resident #1 required one to one supervision, or a higher level of care. Resident #1 was not provided with sufficient supervision which resulted in resident #1 sustaining multiple 1st and 2nd degree burns.	8 9 10 11 12 13 14

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) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

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