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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 01/23/2025
Date Signed: 01/23/2025 02:56:12 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
01/14/2025 and conducted by Evaluator Perchui Khurshudyan
COMPLAINT CONTROL NUMBER: 31-AS-20250114084446
FACILITY NAME:GLEN PARK AT GLENDALE - BOYNTON STFACILITY NUMBER:
197608505
ADMINISTRATOR:SUSAN PARKFACILITY TYPE:
740
ADDRESS:1250 BOYNTON STTELEPHONE:
(818) 246-9000
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:98CENSUS: 73DATE:
01/23/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Susan Park - AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not provide resident’s records to resident’s authorized representative.
INVESTIGATION FINDINGS:
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On 1/23/2025 at 11:00am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced initial ten-day visit to investigate the above allegation. Upon arrival, LPA met with Brenda Chucon – the office manager (OM), introduced herself by showing her badge and explained the reason for the visit. Facility Administrator Susan Park arrived shortly after and helped with the investigation process.

At 11:15am, LPA requested resident and staff rosters, copies of pertinent information which include, but not limited to Policy and Procedures for processing Subpoenas/Record requests., and other relevant documents to support the investigation. LPA conducted a physical plant tour, to ensure health and safety of the residents are protected.
During course of the investigation, interviews and record review were made. Between 11:25am – 12:45pm, LPA conducted interviews with the Administrator, Office manager (OM), and (QA) Quality Assurance representative Rafael Silva.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
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-20250114084446
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: 01/23/2025
NARRATIVE
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Allegation: Staff did not provide resident’s records to resident’s authorized representative.

It was reported that agency submitted initial record request on October 30th, 2024, to receive copies of complete files on behalf of R1 and R2. LPA requested documentation and observed that agency requested the facility to submit copy of complete files within five (5) business days. After several attempts made by the agency, S1 provided partial documents to the agency on December 13th, 2024, via email. Agency submitted another request on December 19th, 2024, to receive the documents not provided by the facility. After no response and failing to submit requested copy of complete file, the agency submitted another request on January 6th, 2025, via mail and email. Interview with witness from the agency revealed that facility did not provide full requested documents until January 22, 2025 which confirms facility did not comply Title 22 Code of Regulations and agency's request.

Therefore, based on records review and interviews, this allegation is deemed Substantiated.

Exit interview conducted and copies of this report delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20250114084446
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: 01/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2025
Section Cited
CCR
87468.2(a)(19)
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Personal Rights...(19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.
This requirement is not met as evidenced by:
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LPA cleared during the visit. The facility had already provided the requested documents on 01/22/2025.
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Based on record review and interview the licensee did not provide the records of R1 and R2 to the authorized representative in a timely manner which poses a potential personal rights risk to the residents 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
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