197608505-10-31-2023-31-AS-NMAN-D77SPL-20240715140317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 10/31/2023
Date Signed: 10/31/2023 04:51:52 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
10/30/2023 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20231030103931

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: 65	DATE:	10/31/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Peter Bonilla, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff mismanaged resident's medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Administrator Peter Bonilla and explained the reason for the visit.

It was reported that staff mismange Resident #1 (R1)'s medication. To investigate this allegation on 10/31/2023 between 1:00pm and 2:30pm, facility records were reviewed. Between 3:00pm and 3:30pm, staff interviews were initiated. Staff interviews revealed that approximately six weeks ago a medication error occurred. R1 was given Resident #2 (R2)'s medication and R2 was given R1's medication. The medication was mixed up by a former staff member. Staff #1 (S1) was terminated and no longer works at the facility. Between 3:35pm and 3:50pm, LPA interviewed R2. Interviews confirmed what staff told LPA. R2 stated that their medication was mixed up.

Based on interviews there is sufficient information to support this allegation. Therefore, this allegation is SUBSTANTIATED at this time.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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-20231030103931

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: 10/31/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/14/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465-Incidental Medical & Dental Care (c) If the resident 's physician stated in writing that the resident is able to determine his/her own precription medications...the licensee shall be permitted to assist resident with self administration...(2) Once ordered by the physcian the medication is given	1 2 3 4 5 6 7	The Licensee shall submitted in writing to the deparment by 11/14/2023, how they will ensure that medication errors do not occur. In addition, the Licensee shall provide medication training to staff and show proof to the Department that training was completed.
	8 9 10 11 12 13 14	the physcian the medication is given according to the physician's directions. This requirement was not met as evidenced by...The facility staff mixed up the medication of R1 and R2. Each were given the wrong medication. This poses an immediate and health and safety risk 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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC9099 (FAS) - (06/04)

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