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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 10/09/2025
Date Signed: 10/09/2025 12:51:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
09/29/2025 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20250929135423
FACILITY NAME:GLEN PARK AT GLENDALE - BOYNTON STFACILITY NUMBER:
197608505
ADMINISTRATOR:SUSAN PARKFACILITY TYPE:
740
ADDRESS:1250 BOYNTON STTELEPHONE:
(818) 246-9000
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:98CENSUS: 67DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Edwin SanchezTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not provide resident medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to conclude the investigation regarding the above allegation. LPA met with the assistant administrator, Edwin Sanchez and advised him of the complaint. Today’s investigation consisted of interviews with the administrator and staff. LPA also conducted a record review and a physical plant inspection.

In regards to the allegation, it’s being reported that on or around 09/26/25, Resident 1 (R1) was packed another resident’s (Resident 2 (R2)) medication for R1’s outing. Both resident’s take Memantine. R1’s dosage for the Memantine is 5mgs, but instead of packing R1’s Memantine for 5mgs, R1 was packed R2’s Memantine for 10mgs. In addition, R1 was packed several of R2’s other medications, which were Atorvastatin, Donepezil, and Tamsulosin. Pictures of this medication error was included as proof R1 was packed the wrong medication for their outing. It was also identified that this packing of medication error,
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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 3
Control Number 31-AS-20250929135423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST
FACILITY NUMBER: 197608505
VISIT DATE: 10/09/2025
NARRATIVE
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between both these two residents, has occurred by the same staff, Staff 1 (S1) in the past. S1 was trained and instructed to review and differentiate both these residents medications when packing, but S1 made the same mistake.

Interviews with both administrator and one (1) of one staff were held between 9:15am-10:15am to discuss the package, preparation and distribution of resident medications during outings. At around 10:15am - 12:15pm, LPA conducted a physical plant inspection of the medication room to observe and review centrally stored medication and medication documentation. LPA attempted to interview six (6) of six residents between 12:15pm to 1:00pm, but due to the diagnoses of these residents, LPA was unable to get a consistent interview.

Although corrections are in place to address this medication error, based on the information obtained, the allegation of staff providing or packing the wrong medication for R1 is Substantiated. Citation issued on the 9099D. Administrator advised and a copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250929135423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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: 10/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2025
Section Cited
CCR
87411(d)(4)
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Personnel Requirements: All personnel shall be given on the job training or have related experience with knowledge required to safely assist with prescribed medications. This requirement was not met as evidenced by: on or around 09/26/25, R1 was packed R2's medication in error, for R1's outing. This
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As POC, S1, will receive on the job training to address this section of the regulation. As proof training is held, licensee will submit attendance log with training topic, addressing section 87411(d)(4) to CCL by 10/16/25
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posed a potential health and safety risk to the resident 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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
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