197608506-9-20-2021-28-AS-CYEE-C8Y4HY-20211120180755

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 09/20/2021
Date Signed: 09/20/2021 02:45:02 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
10/12/2020 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201012151908

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:	09/20/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Rachel De Chavez		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Lack of supervision resulting in resident eloping from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Assistant Administrator Rachel De Chavez and explained the reason for the visit.

The investigation consisted of: On 10/19/20, LPA conducted an interview with Office Manager Leticia Flores and obtained copies of Staff and Resident Rosters. On 9/20/21, LPA collected copies of Staff and Resident Rosters, conducted interviews with Assistant Administrator Rachel De Chavez at 10:15am -10:30am, Office Manager Leticia Flores at 10:45am, Receptionist Siranush Aleksanyan at 11:00am, Activity Director Shirley Lee at 11:15am and Residents 1-7 (R1-7) from 11:30-12:30pm. LPA also reviwed R8's facility file and

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

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-20201012151908

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: 09/20/2021

NARRATIVE

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collected copies of the following documents: Glen Park at Glendale - Mariposa Internal Incident Report dated 6/1/21, Physician's Report for Residential Care Facilities for the Elderly (LIC602A) dated 3/11/20 and 6/10/21, Appraisal/ Needs and Services Plan (LIC625) dated 7/14/20 and 3/6/21, Preplacement Appraisal Information dated 3/1/19, Resident Appraisal dated 3/2/19 and Functional Capability Assessment dated 3/1/19. LPA additionally attempted to interview R8's responsible party.

The investigation revealed the following: Regarding allegation, Lack of supervision resulting in resident eloping from facility, it is alleged Glendale Police Department officer was dispatched to a business on 10/22/20 at approximately 2:45pm due to a report of a lost elderly person (R8). Glendale PD officer stated that store employee reported to officer that R8 walked into the business and told the employee that they were lost. Upon contact with R8, the resident was not able to provide the officer with their birthday, where they where or where they lived and R8 did not have any contact information for family. Glendale PD officer called the facility at approximately 3:33pm to inquire if R8 was missing and was advised by a facility employee that R8 was missing. Officer stated that it appeared that facility staff were not aware that R8 was missing. Interview with Office Manager Leticia Flores revealed that R8 was missing from the facility on 10/22/20 when Glendale PD officer called to inquire if R8 was a resident of the facility. Ms. Flores stated that R8 exhibited exit seeking behaviors especially in the afternoon. Ms. Flores stated that facility staff would regularly redirect R8 and R8 would not succeed in their attempt to elope but on 10/22/20 as the facility was receiving their delivery of groceries the delivery truck parked in an area that blocked the camera view and facility office staff did not see R8 exit the facility. Office Manager stated that R8 was transferred to Glen Park at Glendale - Boynton St due to resident requiring more supervision due to increased exit seeking behavior and also needing a higher level of care. Office Manager Flores stated that since that incident the deliveries are made in an area that does not block camera footage and a staff stands at the gate until delivery is complete to ensure that residents do not exit the facility. Based on interview conducted with facility staff and and LPA review documents, the preponderance of evidence standard has been met; therefore, the above mentioned allegation is found to be SUBSTANTIATED.

Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit. (Refer to LIC 9099D).

Exit interview was conducted with Assistant Administrator Rachel De Chavez. A copy of the report and appeal rights were provided to Assistant Administrator.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20201012151908

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/21/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Health and Safety Code section 1569.2(c) provides: "Care and supervision" means the facility assumes responsibility for, or provides or	1 2 3 4 5 6 7	Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Executive Director to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement is not met as evidenced by: Based on interview with facility staff who confirmed that R8 did elope from the facility on 10/22/20 and was found at a local store and brought back to facility by Glendale PD. R8 was not provided with adequate care and supervision on 10/22/20, which poses an immediate risk of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

LIC9099 (FAS) - (06/04)

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