197608505-9-12-2024-31-AS-NMAN-DAHQR5-20241029122323

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:05:57 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
09/05/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240905124218

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:	09/12/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Rafael Silva		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility does not provide a safe environment for the residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with administrator, Rafael Silva, and explained the reason for the visit.

--- Facility does not provide a safe environment for the residents.

It was alleged that Resident #1 (R1) had been pushed to the ground by Resident #2 (R2) and R2 also assaulted three (03) staff members prior to the incident. To investigate the allegation, LPA interviewed four (04) staff from 11:00 AM – 1:00 PM and reviewed pertinent documents at 1:30 PM. During interviews, all staff stated R2 was aggressive that day, assaulted three (03) staff. Staff #1 stated R2’s nurse practitioner and physician were alerted about the change in condition, an ambulance was called for a 5150 hold and that paramedics stated they would arrive in a few hours.
(CONT. on LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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-20240905124218

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: 09/12/2024

NARRATIVE

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All staff added that while R2 was in their room waiting to be transported, R1 was passing by and R2 told R1 to leave the area and raised their arms as though they were about to do something to R1. At that moment Staff #2 (S2) was in the area and shouted out “don’t” but by then it was too late. R2 pushed R1 to the ground. S1 then called 911 again and paramedics took R1 to the hospital and R2 to the 5150 hold. A review of the department’s records confirmed the incident and details.

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 noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 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
09/05/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240905124218

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:	09/12/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Rafael Silva		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility does not employ sufficient staff to meet the needs of the resident.
Physical abuse incident was not reported to required agencies.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with administrator, Rafael Silva, and explained the reason for the visit.

--- Facility does not employ sufficient staff to meet the needs of the resident.

It was alleged that facility is unable to provide sufficient care to all the residents. To investigate the allegation, LPA interviewed four (04) staff from 11:00 AM – 1:00 PM, reviewed pertinent documents at 1:30 PM and interviewed six (06) residents from around 1:30 PM to 3:00 PM. During interviews, all staff stated facility has at least five (05) caregivers per shift along with other support staff such as MedTechs and Wellness Nurses. Staff stated that they provide incontinent care to eight (08) to ten (10) residents each and shower up to three (03) residents per day per shift.
(CONT. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 31-AS-20240905124218

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: 09/12/2024

NARRATIVE

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Staff added that facility has call buttons for immediate attention and caregivers are divided into four (04) zones for supervision with one (01) caregiver that floats throughout the other zones as needed. A review of the facility’s staff roster confirms staffs’ statements regarding scheduling and availability. During interviews with residents, all residents stated that staff are sufficient in numbers, and competent to provide the services necessary to meet their needs.

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

--- Physical abuse incident was not reported to required agencies.

It was alleged that staff did not notify local law enforcement. To investigate the allegation, LPA interviewed four (04) staff from 11:00 AM – 1:00 PM and requested documents at around 1:30 PM. During interviews, all staff stated that after contacting the paramedics, facility contact the Glendale Police Department, but by the time they arrived, the paramedics left with R2 for the 5150 hold. A review of the facility’s incident report states that law enforcement was contacted after the incident and identifies the officer’s name that took the police report including the department, bureau and contact information.

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

No other health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20240905124218

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: 09/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/16/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities; (a) Residents in all residential care facilities for the elderly shall have the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	The Administrator will provide written information explaining the steps the facility will take to ensure that all residents’ health, safety and personal rights are protected at the facility.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by; Based on interviews and record review, the facility did not ensure that the residents treat each other with dignity and respect which poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type A 09/16/2024 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, residents in privately operated residential care facilities for the elderly shall have all of the following..(8)..free from ...physical...abuse	1 2 3 4 5 6 7	The Administrator will provide written information explaining the steps the facility will take to ensure that all residents’ health, safety and personal rights are protected at the facility.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by; Based on interviews and record review, the facility did not ensure that the residents was free from physical abuse which poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

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