197608506-6-2-2022-28-AS-FFIS-CFFTVC-20220616150341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 06/01/2021
Date Signed: 06/02/2022 06:33:51 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
05/26/2021 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20210526161530

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: 65	DATE:	06/01/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Rachel De Chavez, Assistant Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is in disrepair.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

***This report serves as an amendment and supersedes the original complaint investigation report created on 06/01/2021. The purpose of this amended Licensing report is to change the finding to unsubstantiated. ***
Licensing Program Analyst (LPA) Tao conducted an initial complaint investigation of the above allegation on 06/01/21 and subsequent visit on 06/02/22. LPA discussed the purpose of the visit to Rachel.
On 06/01/21, investigation consisted of staff interviews from staff#1 to staff#4; resident interviews from resident #1 to resident #8; review of maintenance log; and obtained Resident roster and Staff roster.
For the allegation of “facility is in disrepair”, investigation revealed that facility's underground water pipe had burst and water was off for a half day on 05/25/21 and 05/26/21 to complete the repair. Plumbing issue was completed on 05/26/21. Seven out of seven residents confirmed the facility’s water was off only half day and had water supply for half day. Four out of four staff interviewed confirmed water was off due to facility’s plumbing issues at the underground pipe. Incident report was filed to address the issue. Since facility had no control on the plumbing issue of the underground water pipe, administrator had done diligent work to handle the plumbing issues on a timely basis.
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.

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)

Page: 1 of 3

Control Number 28-AS-20210526161530

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: 06/01/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Per staff interviews, it reported that the facility had plumbing issues related to underground pipe. An outside plumber was not contacted, and all plumbing issues were handled by maintenance staff. Administrator stated the plumbing issue was repaired.

Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 05. See LIC 9099 D for citation details.
An exit interview was conducted with Administrator. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20210526161530

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: 06/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 06/01/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a).Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Administrator had maintainence staff to repair the plumbing issue and water was back on normal on May 26,2021. Issue was fixed. POC is cleared at visit.
	8 9 10 11 12 13 14	Based on observation during record review and interviews conducted, facility has had plumbing issues and water was off on May 25 and May 26 2021. Plumbing issue and water issues were observed to be in need of repairs.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3