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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608505
Report Date: 03/27/2024
Date Signed: 03/27/2024 01:05:13 PM


Document Has Been Signed on 03/27/2024 01:05 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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: 72DATE:
03/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Chanel SanchezTIME COMPLETED:
01:30 PM
NARRATIVE
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On 03/27/24 LPA Casillas arrived at facility above to conduct an initial 10-day complaint investigation for complaint # 31-AS-20240325110125. This Case Management is not related to the original complaint visit. During the facility tour LPA observed that cleaning supplies were unlocked and unsupervised. This allowed residents to have access to cleaning supplies.

During LPA’s tour with Executive Director (ED), LPA observed that a hallway closet with a sign that read “Cleaning Supplies” was not locked. Upon seeing this ED immediately locked the closet making it inaccessible to residents.

LPA explained to ED the importance of locking all closets that store harmful products. LPA explained to ED that a citation would be issued for this deficiency. LPA also advised ED that there would need to be a training of all staff on the importance of keeping harmful items locked for resident safety. ED will email LPA a copy of the training that was provided along with a log of all staff that was in attendance by end of POC date.

Citation Issued. Appeal rights discussed and provided. Exit Interview conducted.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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 03/27/2024 01:05 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
WOODLAND HILLS S.RO, 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: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2024
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication,..and toxic substances such... cleaning supplies and disinfectants. This requirement was not met as evidence by:
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Hallway closet was locked in LPA’s presence. Executive Director will email LPA a copy of the training that was provided along with a log of all staff that was in attendance by end of POC date.
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Based observation, staff do not ensure that cleaning supplies were locked and inaccessible to clients, this poses an immediate health and safety and personal rights risk to persons in care.
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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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
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