197608505-3-27-2024-31-AS-NGID-D59PTA-20240514113536

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 03/27/2024
Date Signed: 03/27/2024 01:07:00 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
03/25/2024 and conducted by Evaluator Lorena Casillas

COMPLAINT CONTROL NUMBER: 31-AS-20240325110125

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: 72	DATE:	03/27/2024
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Chanel Sanchez		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in residents engaging in a physical altercation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced complaint visit to the facility to investigate the above allegation. LPA met with Executive Director (ED), Chanel Sanchez, and explained the reason for the visit.

Allegation #1 Staff did not provide adequate supervision resulting in residents engaging in a physical altercation.

It was alleged that on 03/23/2024, Resident #1 (R1) entered Resident #2 (R2)’s room and an altercation began where R1 was pushed by R2 resulting in R1 falling and injuring themselves. To investigate the allegation, on 03/27/2023 LPA conducted physical plant tour at around 10:50 AM, interviewed five (05) staff and ED at 11:30 AM and requested records at 12:30 pm.

(CONT. on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240325110125

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/27/2024

NARRATIVE

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During interviews with staff, staff stated that on 03/23/24 R1 entered R2’s room and they were holding on to each other, when R2 took a step forward R1 was propelled backwards and fell injuring themselves. 911 was then called and police, fire and rescue showed up. Record review revealed R1 requires safety measures to address behaviors such as wandering. Staff were not aware of what was happening until R2’s roommate Resident #3 (R3) went to get staff. Staff were not paying attention to cameras and were not aware of what was happening.

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

Being that this is the second time that this citation is issued in less than 12 months LPA explained to ED that this will be a repeat violation with a civil penalty of $250.

Please refer to LIC9099-D.

Citation was issued. Appeals rights discussed and provided. Exit interview was conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240325110125

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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(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	Administrator agreed to review Dementia plan with proof of acknowledgment, will submit a new LIC500 to reflect enough staff for supervision of residents, and will provide Care and Supervision training for all staff to be given by a vendor, all proof will be emailed to LPA by POC due date.
	8 9 10 11 12 13 14	Facility staff did not ensure that the needs of dementia residents were properly addressed. Based on interviews and observations facility staff failed to ensure R1 was supervised by staff which poses an immediate health, safety and hazard to residents in care.	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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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