197608506-9-15-2022-28-AS-MVAO-CJFNCW-20220920102121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:14:32 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
09/24/2021 and conducted by Evaluator Elizabeth Ceniceros

COMPLAINT CONTROL NUMBER: 28-AS-20210924163328

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: 70	DATE:	09/15/2022
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Asst. Administrator, Rachel de Chavez		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility failed to meet resident's needs.

Resident's personal belongings are missing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Asst. Administrator (A2: Rachel de Chavez). LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms.

The purpose of today’s visit is to deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day visit was conducted by LPA Nicol Wesley on 10/01/21. LPA/RA Ceniceros re-interviewed (between 2:15 p.m. - 2:40 p.m.) Asst. Administrator (A2: Rachel de Chavez) and Witness #1 (W1: Dr. James Lee, M.D.). Resident #1 was not re-interviewed; as the resident moved on 08/16/22 and the contact numbers were out of service. LPA/RA Ceniceros reviewed (between 2:45 p.m. – 3:20 p.m.) the requested documents: Emergency I.D. & Information Face Sheet, Physician’s Report (dated 06/22/22) - including additional documents: PRN Authorization Letter (dated 09/07/21), Medication Administration Record (September 2021), Safeguards for Property/Valuables for Resident #1 (R1); and Staff & Residents Roster.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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-20210924163328

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: 09/15/2022

NARRATIVE

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Regarding Allegation #1: this investigation revealed that Resident #1 was requesting the pain medication (Acetaminophen 325 mg.) every two (2) hours. LPA/RA Ceniceros reviewed the physician's order from Witness #1 (W1: Dr. James Lee, M.D.) that was issued in a "PRN Authorization Letter" (dated 09/07/21) for PRN medication (Acetaminophen 325 mg) to be administered: two (2) tablets (650 mg) by mouth every four (4) hours as needed for pain. A review of the resident's Medication Administration Record (MAR) for the month of September 2021 documented that the resident had been administered the PRN medication (Acetaminophen 325 mg) every four (4) hours as needed for pain (from 09/02/21 thru 09/30/21).

Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Facility failed to meet resident's needs is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that Resident #1 was admitted to the facility on 05/25/21. LPA/RA Ceniceros reviewed the resident's "Personal Property Inventory" (signed and dated 05/25/21) by Resident #1 that did not document the resident brought a brown suitcase and/or Filipino costume with other personal belongings upon facility move in.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of OTHER: Resident's personal belongings are missing is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Asst. Administrator (Rachel de Chavez).

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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