197608506-10-22-2021-28-AS-LHIS-C8DUBG-20211102152615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 10/22/2021
Date Signed: 10/22/2021 05:01:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2021 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211020141223

FACILITY NAME:	GLEN PARK AT GLENDALE - MARIPOSA ST		FACILITY NUMBER:	197608506
ADMINISTRATOR:	PINK, MARINA		FACILITY TYPE:	740
ADDRESS:	1220 S MARIPOSA ST		TELEPHONE:	(818) 242-9000
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	120	CENSUS: 64	DATE:	10/22/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Assistant Administrator, Rachel De Chavez		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident is being harassed by another resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegation. LPA met with Administrator, Marina Pink and Assistant Administrator, Rachel De Chavez who assisted with today's visit.

Regarding the allegation that resident is being harrassed by another resident. The investigation consisted of interviews with administrator, assistant administrator, interviews with residents #1 - resident #5, and review of resident #1 and resident #2 files.

The investigation revealed that there was an incident on 9/17/21, involving resident #1 and resident #2. Resident #1 stated that resident #2 came to his room, holding an aersol can and threatening to spray it at him. Resident #2 stated that she was holding an aerosol can, but she did not threaten resident #1. Staff interviewed stated that resident #1 and resident #2 have an ongoing issue due to resident #1's playing his music too loudly for resident #2's liking. Resident #3 witnessed the incident, and stated that he did not observe resident #2 threatening resident #1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

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 28-AS-20211020141223

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 ST	FACILITY NUMBER: 197608506
	VISIT DATE: 10/22/2021

NARRATIVE

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Staff stated that both residents have been counseled regarding the incident, and staff have taken measures to resolve the issues between resident #1 and resident #2. Staff stated that they submitted a special incident report (SIR) to Community Care Licensing as required. LPA Rea obtained a copy of the SIR on today's visit.

Other residents interviewed were unable to corroborate the allegation. They stated that they have not observed any resident(s) being harassed by another resident at the facility.

Based on LPA's observations and interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of the report was provided to Assistant Administrator.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

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