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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608506
Report Date: 02/11/2021
Date Signed: 02/11/2021 10:02:02 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GLEN PARK AT GLENDALE - MARIPOSA STFACILITY NUMBER:
197608506
ADMINISTRATOR:PINK, MARINAFACILITY TYPE:
740
ADDRESS:1220 S MARIPOSA STTELEPHONE:
(818) 242-9000
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:120CENSUS: 57DATE:
02/11/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Spoke to Sara Aleksanyn, ReceptionistTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Vasallo initiated a Plan of Correction (POC) visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with Sara Aleksanyn, receptionist. LPA called the facility at 8:34 am. Leticia Flores, facility manager was explained that a POC visit had to be made. Leticia stated that Marina Pink, administrator will be corresponding with LPA. LPA did not receive a call back, therefore the facility was called again at 9:04 am. LPA requested to speak with Leticia and Sara Aleksanyn, receptionist said Leticia was not available. LPA explained the reason for the call was to follow-up on the POCs that were due on 2/2/21. LPA explained to the receptionist that the POC were never submitted and deficiencies had to be issued. LPA notified the receptionist that the report will be completed and emailed to Leticia Flores and Marina Pink.

On 2/1/21, LPA delivered the substantiated findings for a complaint dated 2/27/20 (28-AS-20200227151727). The following allegations were substantiated; Severe neglect resulting in resident developing a stage 4 pressure injury; Facility retained a resident beyond their level of care. The investigation was conducted by investigator, Garcia. The following regulations were cited on 2/1/21: 1569.49(c)(1), 87615(a)(1), 87463(a)(3), 87468.1(a)(2), and 87405(d)(1). The POCs for these deficiencies were never submitted. Therefore, civil penalties will be assessed today for late POCs.

This report along with civil penalty forms and appeal rights were emailed to Leticia Flores and Marina Pink for review and signature.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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