197608506-6-2-2022-28-AS-FFIS-CFFUJL-20220616153743

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 06/02/2022
Date Signed: 06/02/2022 06:33:18 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
05/24/2022 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20220524162211

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:	10:30 AM
MET WITH:	Rachel De Chavez, Assistant Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident belongings not safeguarded.
Resident’s medications are being mismanaged

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an Initial 10-Day complaint investigation regarding the above allegations. LPA discussed the purpose of the visit with Assistant Administrator, Rachel De Chavez.

Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #4 (S4); interviews of residents from Resident#1 (R1) through Resident #6 (R6); reviewed resident#1’s (R1) record reviews, and a facility tour. LPA obtained copies of the Staff and Resident Rosters; and residen files for Resident #1 (R1) with relevant information.

The investigation revealed the following:
For the allegation of “resident belongings not safeguarded”, it was alleged that resident#1 had several items stolen from resident's room.

(-continued in LIC 9099 C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
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-20220524162211

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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Five (5) out of six (6) residents could not corroborate the allegation. Resident interviews from R2 through R6 revealed that staff safeguarded residents’ belongings and residents did not have items missing from their rooms. Interview with R1 stated resident had belongings missing since moved in. Four (4) out of four (4) staff denied the allegation. Staff interviews revealed that facility would safeguard residents’ belongings. Staff said that residents’ belongings were mostly misplaced if they were reported missing. File review revealed R1 did not have the procession of the missing items upon admission to the facility. LPA visited resident#1 in resident’s room and observed the said missing items were in resident’s closet.

In regard to allegation: “Resident’s medications are being mismanaged”, it was alleged that staff did not administer one of R1’s medication as prescribed three times a day in a timely basis. Five (5) out of six (6) residents could not corroborate the allegation. Resident interviews from R2 through R6 revealed that staff administer residents’ medication as prescribed. Interview with R1 stated resident did not get medication as prescribed. Four (4) out of four (4) staff denied the allegation. Staff interviews revealed staff did not mismanage resident’s medication. LPA reviewed R1’s medication record, it revealed that R1’s medication is PRN which is administered as needed, not on a routine basis of three times a day. The investigation did not reveal staff mismanaged resident’s medications.

Although the allegations 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.

No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted with Assistant Administrator. A hard copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
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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