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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 06/19/2024
Date Signed: 06/19/2024 04:47:05 PM

Substantiated


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
06/12/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20240612080940
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: 66DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Brenda Chacon, Office ManagerTIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Facility’s phone is inoperable.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with Office Manager, Brenda Chacon, and explained the reason for the visit.

--- Facility’s phone is inoperable.

It was alleged that facility phone lines have been down for over five (05) days. To investigate the allegation, LPA conducted a physical plant tour at around 11:00 AM, interviewed five (05) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. During the physical plant tour, LPA observed the facility’s telephones to be fully operational. During interviews with staff, all staff stated that facility could not receive incoming calls for two (02) to five (05) days.

(CONT. on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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 5
Control Number 31-AS-20240612080940
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: 06/19/2024
NARRATIVE
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Staff added that the Department and responsible parties were notified of the issue and provided alternate contact numbers and an email address. During interviews with residents, all residents were unaware of the facility having issues with the telephones.

Based on interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No other health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20240612080940
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by; Based on interviews, the facility was without a fully functional phone for two to five days which poses a potential health,
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Although the facility telephone was not in working order, the facility took measures to have the telephone repaired, therefore, a Plan of Correction will not be issued at this time.
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safety and personal rights risk to 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.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/12/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20240612080940

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: 66DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Brenda Chacon, Office ManagerTIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Facility does not have adequate staff to meet the needs of the residents.
Staff are unable to communicate effectively with resident.
Staff burned resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with Office Manager, Brenda Chacon, and explained the reason for the visit.

--- Facility does not have adequate staff to meet the needs of the residents.

It was alleged that residents are left in the activities room without activities, care and supervision when the Activities Director is off on Sundays and Mondays. To investigate the allegation, LPA conducted a physical plant tour at around 11:00 AM, interviewed five (05) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. During the physical plant tour LPA observed a full activities calendar in the hallway.
(CONT. LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20240612080940
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: 06/19/2024
NARRATIVE
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During interviews with staff, five (05) out of six (06) staff stated residents have activities on Sundays and Mondays and are never left without care and supervision. Staff #4 stated they do not know about what takes place on Sundays and Mondays as they do not work as a caregiver during those days. During interviews with residents, all residents stated they have activities on Sundays and Mondays and are not left without care and supervision for an extended time.
Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff are unable to communicate effectively with resident.

It was alleged that staff are unable to communicate with staff due to a language barrier. To investigate the allegation, LPA interviewed five (05) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. During interviews with staff, all staff stated all caregivers are able to communicate effectively to meet the needs of the residents. During interviews with residents, all residents stated they can communicate with staff effectively and that they meet all their needs.
Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff burned resident.

It was alleged that staff burned resident in the shower with hot water. To investigate the allegation, LPA conducted a physical plant tour at around 11:00 AM, interviewed five (05) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. During the physical plant tour LPA observed average hot water temperature measured at 111.6 degrees Fahrenheit. During interviews with staff, all staff stated they are unaware of any resident being burned with hot water in the shower by staff. During interviews with residents, all residents stated they have never been burned by staff with hot water in the shower. LPA was unable to interview Resident #1 (R1).
Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
No health and safety hazards were noted during the visit.
Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5