197608505-9-20-2023-31-AS-NMAN-CYHVS9-20231214154111

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 09/20/2023
Date Signed: 09/20/2023 03:53:30 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20230913123339

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:	09/20/2023
		UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Peter Bonilla, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not provide adequate supervision, resulting in a resident wandering away from the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced complaint visit to the facility to investigate the above allegation. LPA met with Executive Director, Peter Bonilla, and explained the reason for the visit.

--- Staff did not provide adequate supervision, resulting in a resident wandering away from the facility.

It was alleged that on 09/13/2023, Resident #1 (R1) was found by police to be wandering an apartment complex’s courtyard, appeared to be lost and unable to follow instructions. To investigate the allegation, on 09/20/2023 LPA conducted physical plant tour at around 10:15 AM, interviewed 02 (two) staff at 11:15 AM and requested records at 12:15pm. During the physical plant tour, LPA observe the delayed egress doors in working condition.

(CONT. on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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 31-AS-20230913123339

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST	FACILITY NUMBER: 197608505
	VISIT DATE: 09/20/2023

NARRATIVE

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During interviews with staff, all staff stated that on the evening of 09/13/2023, Staff #3 (S3) fell asleep while on camera duty and Staff #4 (S4) was assisting other residents when the delayed egress alarm sounded. Staff #1 (S1) and Staff #2 (S2) added that police brought R1 back to the facility before S3 and S4 could finish their room-to-room inspection for any wanderers. Record review revealed R1 requires safety measures to address behaviors such as wandering.

Based on interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230913123339

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST	FACILITY NUMBER: 197608505
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/22/2023 Section Cited CCR 87705(b)(2)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (b) (2) ...the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering, aggressive behavior...This requirement is not met as evidence by;	1 2 3 4 5 6 7	The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87705 Care of Persons with Dementia; The written letter must be sent to the LPA by the POC due date.
	8 9 10 11 12 13 14	The Licensee did not ensure that the needs of dementia residents were properly addressed. Based on interviews, the licensee failed to ensure R1 was supervised by staff which poses an immediate health, safety and hazard.	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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC9099 (FAS) - (06/04)

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