197608505-10-2-2024-31-AS-NMAN-DJFSBP-20250710134413

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 10/02/2024
Date Signed: 10/02/2024 05:17:02 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.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
04/25/2024 and conducted by Evaluator Rosaura Valenzuela

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240425103743

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:	DATE:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	11:26 AM
MET WITH:	Susan Park, Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility staff did not administer resident's medication as prescribed.

Facility staff did not provide adequate food service to resident in care.

Facility is operating without a certified administrator.

Staff did not ensure that residents are provided activities while in care.

Facility staff did not prevent resident from engaging in a physical altercation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subsequent visit for the above noted allegations. LPA met with Administrator Susan Park and explained the reason for the visit.

On 05/01/2024, LPA Abeye Duguma initiated the investigation. At the time of that visit LPA conducted a physical plant tour, requested pertinent documentation and initiated staff interviews.

It was reported that facility staff did not administer Resident #1 (R1's) medication as prescribed. To investigate this allegation on 10/02/2024, between 11:45am and 1:00pm, LPA initiated staff interviews. Interviews revealed that R1 has and does receive their medication as prescribed by a physician. Between 1:00pm and 2:00pm, LPA requested and reviewed facility records. Records confirmed what staff told LPA.

Based on interviews and records review there is not sufficient information to support this allegation. Thus,

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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 3

Control Number 31-AS-20240425103743

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: 10/02/2024

NARRATIVE

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the allegation is UNSUBSTANTIATED at this time.

It was alleged that facility staff did not provide adequate food service to a resident in care. It was reported that facility does not provide snacks to R1, in between meals. To investigate this allegation on 10/02/2024, between 11:45am and 1:00pm, staff interviews were initiated. Interviews revealed that facility does provide snacks to all residents in care. At 2:30pm, LPA observed staff pushing a cart and offering snacks to residents.

Based on interviews and observation, there is not sufficient information to support this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

It was reported that facility is operating without a certified administrator. To investigate this allegation on 10/02/2024, between 11:45am and 1:00pm, staff interviews were initiated. Interviews revealed that the facility has always had a certified administrator, but acknowledged that there having been changes in staffing. This year the facility has had four different administrators. Between 1:00pm and 2:00pm, LPA requested and reviewed facility records. Records confirmed what staff told LPA.

Based on interviews and records review there is not sufficient information to support this allegation. Thus, the allegation is UNSUBSTANTIATED at this time.

It was alleged that staff did not ensure that residents are provided activities while in care. To investigate this allegation on 10/02/2024, between 11:45am and 1:00pm, staff interviews were initiated. Interviews revealed that facility does provide activities for residents in care. In fact, the facility has two activity directors. Between 1:00pm and 2:00pm, LPA requested and reviewed facility records. Records confirmed what staff told LPA. In addition, LPA observed the activities calendar for month inside the arts and crafts room.

Based on interviews, records review, and observation, there is not sufficient information to support this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

It was reported that staff did not prevent Resident #2 (R2) from engaging in a physical altercation with R1.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20240425103743

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: 10/02/2024

NARRATIVE

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R2 pushed hard R1, causing them to fall and hit their head. To investigate this allegation on 10/02/2024, between 11:45am and 1:00pm, LPA initiated staff interviews. Interviews revealed that staff immediately had R1 accessed and transported to the hospital for further evaluation. Staff also notified R1's responsible party of the incident. R2 was placed on a 5150 and assured everyone that they would not be returning to the community, due to being a danger to others. Staff told LPA that R2 had been placed on 5150 several times and would return to the community after 72 hours. After this incident, facility refused to accept back R2, due to a series of violent incidents. Between 1:00pm and 2:00pm, LPA reviewed incident reports and confirmed what staff had told LPA.

Based on interviews and records review, there is not sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety issues noted at the time of this visit.

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

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

Page: 1 of 1

Control Number 31-AS-20240425103743

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: 10/02/2024

NARRATIVE

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SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3