197608506-6-2-2022-28-AS-WSHO-CF92XU-20220609174744

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 06/02/2022
Date Signed: 06/02/2022 04:34:34 PM

Unsubstantiated

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
05/25/2022 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220525084343

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: 69	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Assistant Administrator Rachel De Chavez		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident is being discriminated against while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Assistant Administrator Rachel De Chavez and explained the reason for the visit.
The purpose of the visit is to investigate the above allegation.
Interviews were conducted from 9:30 AM to 11:30 AM with Assistant Administrator Rachel De Chavez and Resident's R1-R8.
File was reviewed for Resident R8 and SIR's, Physician's Report, and Emergency ID page were submitted.
In regards to the allegation Resident is being discriminated against while in care, based on interviews conducted and information gathered all 8 residents interviewed had not observed any discrimination.
Resident R 8 confirmed that staff are respectful on a daily basis and staff are ok. Stated that unhappy that family member isn't able to stay overnight.
7 of 8 resident's interviewed stated staff are nice, respectful and do a good job.
Staff interviewed stated that they do person centered care and there is no discrimination. Stated that Special Incident Report's (SIR's) were submitted in which family member of Resident R 8 had stayed

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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-20220525084343

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: 06/02/2022

NARRATIVE

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overnight at the facility and was not adhering to facility protocol. Resident R 8 was with family member at 4 AM on patio.
Family member is not allowed to stay overnight which has caused Resident R 1 to be aggressive and law enforcement has been called.

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 allegation is UNSUBSTANTIATED.

An exit interview was conducted.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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