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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 10/01/2024
Date Signed: 10/01/2024 02:20:22 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
09/25/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20240925115531
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: 63DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Susan Park - AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff did not ensure resident was provided with toiletries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Administrator Susan Park and explained the reason for the visit.

LPA conducted physical plant tour at 9:44 AM, requested facility documents relevant to the investigation at 10:13 AM and interviewed residents and staff between 10:40 AM to 1:20 PM. It was alleged that Resident #1 (R1) was told by the staff that R1 had to buy own deodorant and toothpaste. LPA's interview with the administrator and two (2) staff today between 10:40 AM to 1:20 PM revealed that the facility provides toiletries including but not limited to body wash, soap, deodorant, toothpaste, toothbrush, hand and body lotion and shampoo. Further interview with Staff #1 (S1) who was in charge of the toiletries supply at the facility revealed that the care staff are regularly checking residents' toiletries supply and replenish them on a weekly basis. Further interview with the administrator also confirmed that in case a resident needs any toiletries, any resident could inform the office and they will be provided. (continued on LIC 9099)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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 31-AS-20240925115531
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST
FACILITY NUMBER: 197608505
VISIT DATE: 10/01/2024
NARRATIVE
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(continued from LIC 9099)

LPA's interview with R1 today at around 11:40 AM revealed that R1 was provided with all the toiletries R1 needed. LPA's observation during physical plant tour at around 9:50 AM revealed that the facility has sufficient supplies of toiletries in the storage. LPA's interview with six (6) random residents or 10% of current census today revealed that six (6) out of six (6) residents stated that they were regularly provided the toiletries they need.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2