197608505-4-19-2025-31-AS-NMAN-DHTTMH-20250620145110

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 04/19/2025
Date Signed: 04/19/2025 01:07:29 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
09/12/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240912154746

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: 63	DATE:	04/19/2025
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Susan Park		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Illegal eviction.
Staff did not notify resident's responsible party of incident.
Staff did not take appropriate steps to assist resident(s) with rashes.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above noted allegations. LPA met with Susan Park and explained the reason for the visit.

---Illegal eviction.

It was alleged that Resident #1 (R1) would not be accepted back into the facility. To investigate the allegation, on 09/16/2024, LPA Rosaura Valenzuela requested pertinent documents at around 3:30p.m. and interviewed one (01) staff from 4:00p.m. to 4:30p.m. To further investigate the allegation, on 04/19/2025, LPA interviewed one (01) additional staff from 9:30a.m. to 10: 00a.m. and requested additional documents. A review of the Incident Report log indicates that R1 has multiple incidents of physical altercations with staff and other residents.
(CONT. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2025

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-20240912154746

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: 04/19/2025

NARRATIVE

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R1’s most recent incident resulted in the hospitalization of another resident. During interviews with staff, all staff stated resident was placed on a 5150 hold and determine for the safety of R1, staff and other residents, that R1 needed a higher level of care and supervision.

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

--- Staff did not notify resident's responsible party of incident.

It was alleged that Responsible Party (RP) was not aware R1 was placed in the hospital or moved to another location. To investigate the allegation, on 09/16/2024, LPA Rosaura Valenzuela requested pertinent documents at around 3:30p.m. and interviewed one (01) staff from 4:00p.m. to 4:30p.m. To further investigate the allegation, on 04/19/2025, LPA interviewed one (01) additional staff from 9:30a.m. to 10:00a.m. and requested additional documents. A review of the incident report states that facility notified them of the incident and status of the resident immediately. During interviews with staff, all staff stated they did inform the RP and explained to them that R1 would not be returning to the facility due to requiring a higher level of care and supervision.

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

--- Staff did not take appropriate steps to assist resident(s) with rashes.

It was alleged that R1 has been dealing with rashes or scabies for the past four months and it has spread to other residents. To investigate the allegation, on 09/16/2024, LPA Rosaura Valenzuela requested pertinent documents at around 3:30p.m. and interviewed one (01) staff from 4:00p.m. to 4:30p.m. To further investigate the allegation, on 04/19/2025, LPA interviewed one (01) additional staff from 9:30a.m. to 10:00a.m. and requested additional documents. A review of the Physician’s Report does not indicate that R1 had scabies. The Medication Administration Record indicates that resident is using ointment but does not indicate that R1 has scabies rather it states it is for rash/eczema. A review of the Incident Report records do not show any signs of a scabies outbreak during the time in question.

(CONT. on LIC9099-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240912154746

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: 04/19/2025

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	During interviews with staff, all staff stated they are not aware of any scabies outbreak. Based on interviews and records review there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted at the time of this visit. Exit interview conducted and a copy of the report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2025

LIC9099 (FAS) - (06/04)

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