197608506-4-29-2021-28-AS-MVAO-C2PT38-20210504142156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 04/29/2021
Date Signed: 04/29/2021 03:06:53 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
09/14/2020 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200914123230

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: 60	DATE:	04/29/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Leticia Flores		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident was physically assaulted by another resident
Resident is locked in their room
Resident is not fed a good quality of food

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Spencer initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with program manager Leticia Flores.

During the course of the investigation, LPA Spencer conducted telephone interviews with administrator Marina Pink, staff #1-2 (S1-S2), residents #1-6(R1-R6). R5 could not continue interviews due to dementia, and R6 passed away, so a total of 4 resident interviews were completed. LPA conducted a video call which consisted of a tour of the facility's front entry, 3 resident rooms, the cafeteria/dining room, and the food supply. The LPA received and reviewed copies of the monthly menu, staff roster, and resident roster.

***See LIC9099C for continuation of narrative.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

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-20200914123230

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: 04/29/2021

NARRATIVE

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The investigation revealed the following:

Resident was physically assaulted by another resident- The administrator and S1-S2 denied the allegation that a resident was physically assaulted by another resident. Instead, staff stated that a previous resident verbally attacked R2 but she no longer lives at the facility. LPA Spencer observed the resident roster and confirmed that the individual is no longer residing at the facility. R1 also stated that the previous resident verbally attacking R2 but did not physically assault anyone. R3-R4 stated that they were unaware of a resident attacking another resident but R4 stated that a developmentally disable resident hit him but the staff witnessed it and intervened.
Resident is locked in their room - The administrator and S1-S2 denied the allegation that residents are locked in their room. Staff stated that residents may be quarantined for 14 days due to COVID-19 but residents are never locked in their room. They stated that residents who are not in quarantine eat in the dining room while residents who are in quarantine get meals delivered to their room. All residents stated that they are not locked in their room and can leave freely. LPA Spencer observed that resident doors manually lock from the inside and did not observe any resident being locked in their room.
Resident is not fed a good quality of food - All staff and residents interviewed stated that the quality of the food is good and that there are a variety of foods offered. The administrator stated that the facility has an external dietician that comes to evaluate the menu and that each meal has a base and a special option in which residents can customize their meal. During the virtual tour, LPA Spencer observed the menu, food supply, and perishable/non-perishable choices. There were sufficient perishables, non-perishables, and fresh foods available. LPA also reviewed the monthly menu which listed a variety of food options.

Based upon physical plant observation, interviews conducted, and documents reviewed, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) areUnsubstantiated.
A telephonic exit interview was conducted with program manager Leticia Flores and a hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC9099 (FAS) - (06/04)

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