197608505-6-25-2025-31-AS-NMAN-DJFRZH-20250710132757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 06/25/2025
Date Signed: 06/25/2025 05:49:01 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
11/21/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20241121093525

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: 66	DATE:	06/25/2025
		UNANNOUNCED	TIME BEGAN:	10:34 AM
MET WITH:	Susan Park		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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Staff neglect resulted in a resident's death

INVESTIGATION FINDINGS:

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Licensing Program Analyst, Abeye Duguma, (LPA) conducted an unannounced subsequent complaint visit to the facility. Upon arrival, LPA met with Susan Park and explained the reason for the visit.

---Staff neglect resulted in a resident's death

It was alleged that Resident #1 (R1) may have been dead for a number of hours before being found because no staff member had checked on R1 that day until the afternoon. To investigate the allegation, on 11/22/2024, Licensing Program Analyst Gary Tan conducted an unannounced initial complaint visit, conducted physical plant tour at 9:50a.m., requested copies of facility documents relevant to the investigation at 10:08a.m. and interviewed staff and residents between 10:30a.m. to 11: 45 a.m.

(CONT. on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025

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-20241121093525

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: 06/25/2025

NARRATIVE

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To further investigate the allegation, Investigator Jose Santana (SI) requested additional records and conducted additional interviews.

The interviews with staff revealed safety checks were conducted on residents at minimum of every two (02) hours. The review of the facility records revealed the last documented safety check completed by staff was at 2:00p.m. The interview of the staff assigned to R1 revealed they confirmed checks were completed on R1 throughout the shift and no change in condition was observed. The interview of former staff, S1, revealed they were prompted to go to R1’s room because R1 was not present for the 2:00p.m. scheduled medication distribution in the common area (living room). S1 stated they subsequently went to R1’s room to administer the missed medication, found R1 unresponsive in the bathtub and immediately called 911. The review of the EMS/911 audio records revealed at 3:21p.m., staff requested emergency medical services for R1 who was found unconscious and unresponsive, and EMS personnel determined R1 was dead on arrival due to apneic, pulseless, and without pupillary response state. The review of the death certificate revealed R1’s time of death was noted as 3:29p.m. and the cause of death was listed as acute myocardial infarction (heart attack) within minutes.

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

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025

LIC9099 (FAS) - (06/04)

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