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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 06/03/2021
Date Signed: 06/03/2021 04:49:26 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/16/2020 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20200416083336
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: 61DATE:
06/03/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Brenda ChaconTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit resident
Staff is verbally abusive to resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegations.

As part of this investigation, LPA interviewed the administrator on 4/27/20 telephonically, and 7 residents on 8/7/20 telephonically. On 6/3/21 LPA interviewed 6 residents, 6 staff members, and 2 relevant resident family members in addition to reviewing security camera footage of the alleged incident.

Allegation #1, that "Staff hit resident" has been unsubstantiated based on a review of the facility's security camera footage and the interviews conducted. Security camera footage of this incident showed staff attempting to redirect and calm down Resident #1 (R1), but LPA did not see staff hit R1 at any point. LPA did not receive any corroborating evidence or testimony, besides that of the alleged victim, to support this allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 5964342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
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 2
Control Number 31-AS-20200416083336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST
FACILITY NUMBER: 197608505
VISIT DATE: 06/03/2021
NARRATIVE
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32
Allegation #2, that "Staff is verbally abusive to resident" has been unsubstantiated based on the staff and client interviews conducted. LPA did not receive any corroborating testimony to support this allegation.


Report reviewed and delivered. A hard signed copy will be returned to LPA via email and kept in the facility's file.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 5964342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2