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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 03/23/2025
Date Signed: 03/23/2025 02:04:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/10/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20241210153519
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: 64DATE:
03/23/2025
UNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Dora ChaconTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff interfered with resident's visitation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Dora Chacon and explained the reason for the visit.

---Staff interfered with resident's visitation

It was alleged that facility is refusing visitation without supervision and for no longer than 30 minutes. On 12/18/2024, LPA requested pertinent documents at around 2:30 PM and interviewed one (01) staff from 2:30 PM to 3:00 PM. On 03/23/2025, LPA interviewed one (01) additional staff. A review of Physician’s Report indicates Resident #1 (R1) has a diagnosis of dementia, is confused/disoriented, wanders and unable to leave the community unassisted, manage resources, manage medications or perform activities of daily living.

(CONT on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2025
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 2
Control Number 31-AS-20241210153519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST
FACILITY NUMBER: 197608505
VISIT DATE: 03/23/2025
NARRATIVE
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During interviews with staff, all staff stated they have had disturbing incidents with one of R1’s visitors, that Adult Protective Services recommended supervised visitations for no longer than thirty (30) minutes and witnessed resident staying overnight multiple nights in a row. Staff added that they found this individual in bed with R1, kissing R1 on the lips and having them sit on visitor’s lap. Staff stated visitor also barricades R1’s door with a dresser blocking staff access to care for and supervise R1. LPA was unable to interview Resident #1 due to current health condition.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2