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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 02/01/2021
Date Signed: 02/01/2021 12:44:21 PM

Substantiated


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
02/27/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200227151727
FACILITY NAME:GLEN PARK AT GLENDALE - MARIPOSA STFACILITY NUMBER:
197608506
ADMINISTRATOR:PINK, MARINAFACILITY TYPE:
740
ADDRESS:1220 S MARIPOSA STTELEPHONE:
(818) 242-9000
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:120CENSUS: 55DATE:
02/01/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Leticia Flores, Facility ManagerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Severe neglect resulting in resident developing a stage 4 pressure injury.
Facility retained a resident beyond their level of care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo 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 Leticia Flores, facility manager. LPA conducted the initial complaint visit on 2/28/20. The physical plant was toured and resident and staff files were reviewed. Investigator, Garcia investigated further.

The investigation consisted of the following: Resident #1’s (R1) records were reviewed including but not limited to physician’s report, appraisals, admission agreement, incident reports, medical records and power of attorney. Interviews were conducted with facility administrator, receptionist, caregivers, home health nurse, R1’s primary physician, R1’s family/responsible party

Continued on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
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 7
Control Number 28-AS-20200227151727
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: 02/01/2021
NARRATIVE
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The investigation revealed the following: Administrator was interviewed on 6/29/20. Administrator confirmed R1 resided in the facility from 7/4/19 – 8/3/19. Administrator also confirmed R1 was not receiving home health or wound care. Administrator indicated that on 7/4/19 staff assisted R1 with a shower and noticed only a bruise on the inner left arm. On 7/19/19, staff observed redness on R1’s buttocks. Staff cleaned the area and applied ointment. On 7/22/19, staff observed what was described as a small pink wound on buttocks. Staff called a nurse to assess the wound. The nurse observed the wound at the facility on 7/24/19 and advised staff to send R1 to the hospital Emergency Room (ER) for an evaluation since the stage of the wound was unknown. R1 was transported to the ER. Medical records from the ER confirm R1 was diagnosed with a Stage III pressure injury on 7/24/19. R1 was discharged back to the facility on 7/24/19 and administrator confirmed facility failed to inquire about the stage of R1’s wound upon R1’s return to the facility. Administrator was told that R1’s physician’s report noted redness/skin condition to the Sacro Coccyx area. According to administrator, the caregivers and medication technicians (medtechs) would apply ointment to R1’s wound. The name or type of ointment was not provided. Administrator indicated that the medtech was “fired” due to incompetency. According to administrator, facility attempted to find a home health agency to provide wound care, but due to insurance issues home health services were never provided. R1’s responsible party discharged R1 from the facility on 8/3/19. On 8/5/19, R1 was evaluated by a physician. The assessment indicated a Stage IV pressure injury.

Other facility staff confirmed knowing about the wound but did not know the condition of the wound. Staff confirmed ointment was being applied to the wound. Caregivers interviewed were shown pictures of different stages of wounds. Caregiver(s) described the wound as a Stage III as illustrated in the picture. A review of R1’s records revealed the following: R1’s facility preplacement appraisal dated 7/4/19 indicates R1 needed assistance with bathing, dressing, hygiene, eating, and toileting. Physician’s report dated 7/2/19 indicates R1 had a Stage I pressure injury on the sacro-coccyx area. The post discharge plan from the skilled nursing facility from 7/4/19 has a note from a physician advising the monitoring for skin breakdown related to the sacro-coccyx pressure injury. Physician assessment dated 8/5/19 noted R1 had a pressure injury of sacral region, Stage IV, Candida skin infection.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. The deficiencies are being cited on the attached LIC 9099D. Telephonic exit interview was held with Leticia Flores and a copy of the report and appeal rights were emailed to Leticia Flores for signature. The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49(f); if the department determines serious bodily injury was a result of neglect.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20200227151727
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: 02/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/02/2021
Section Cited
HSC
1569.49(c)(1)
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Civil penalties; regulations setting forth appeal procedures for deficiencies
(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:
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Facility will document the plan to care for residents with pressure injuries. Plan is due by 2/2/21.
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(1) Any violation that the department determines resulted in the injury or illness of a resident.
This deficiency was evidenced by the following: Facility was aware of R1’s skin breakdown issues and did not ensure proper wound care to avoid the worsening of the wound.
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Request Denied
Type A
02/02/2021
Section Cited
CCR
87615(a)(1)
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87615(a)(1) Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
(1) Stage 3 and 4 pressure injuries.
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Facility will document the plan to care for residents with pressure injuries. Plan is due by 2/2/21.
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This deficiency was evidenced by the following:
R1 was admitted to the facility on 7/4/19. On 7/24/19, R1 was diagnosed with a Stage III pressure injury and returned to the facility the same day.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20200227151727
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: 02/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/02/2021
Section Cited
CCR
87463(a)(3)
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87463(a)(3)Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
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Facility will document the plan to insure residents are regularly reappraised for changes in condition. Plan is due by 2/2/21.
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This deficiency was evidenced by the following: On 7/24/19, R1 went to the ER and was diagnosed with a Stage III pressure injury and returned to the facility same day. Facility did not conduct a reappraisal and admittedly did not inquire about the condition of the wound.
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Request Denied
Type A
02/02/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Facility will document the plan to insure residents are provided safe, healthful and comfortable accommodations. Plan is due by 2/2/21.
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This deficiency was evidenced by the following:
Facility documents confirm staff were aware of R1’s skin breakdown issues and failed to properly monitor R1 for pressure injuries and ensure proper care of the wound.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20200227151727
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: 02/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/02/2021
Section Cited
CCR
87405(d)(1)
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87405(d)(1) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). (1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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Facility will document the plan to insure administrator is insuring proper care and supervision is being provided to residents. Plan is due by 2/2/21.
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This deficiency was evidenced by the following: Administrator was aware R1 had skin breakdown issues and that staff were applying ointment to the area. Administrator did not ensure R1 was provided proper wound care and did not inquire about R1’s wound condition after the ER visit.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
02/27/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200227151727

FACILITY NAME:GLEN PARK AT GLENDALE - MARIPOSA STFACILITY NUMBER:
197608506
ADMINISTRATOR:PINK, MARINAFACILITY TYPE:
740
ADDRESS:1220 S MARIPOSA STTELEPHONE:
(818) 242-9000
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:120CENSUS: 55DATE:
02/01/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Leticia Flores, Facility ManagerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility failed to notify resident's responsible party about change in resident's medical condition.
Staff failed to change resident's diapers frequently.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo initiated a subsequent 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 Leticia Flores, facility manager. LPA conducted the initial complaint visit on 2/28/20. The physical plant was toured and resident and staff files were reviewed. Investigator, Garcia investigated further.

The investigation consisted of the following: Resident #1’s (R1) records were reviewed including but not limited to physician’s report, appraisals, admission agreement, incident reports, medical records and power of attorney. Interviews were conducted with facility administrator, receptionist, caregivers, home health nurse, R1’s primary physician, R1’s family/responsible party

Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20200227151727
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: 02/01/2021
NARRATIVE
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The investigation revealed the following: It’s alleged facility did not communicate R1’s health condition with R1’s responsible party. Staff #1 (S1) is a caregiver and indicated she saw R1’s responsible party visiting the facility regularly and would update responsible party on R1’s health condition. Administrator was interviewed and indicated R1’s responsible party was notified of the wound after R1 was diagnosed with a Stage III on 7/24/19. Investigator, Garcia also interviewed family members of other residents in the facility and family members did not corroborate the allegation.

It’s also alleged facility failed to change R1’s diaper frequently. Facility staff interviewed denied the allegation. Staff indicated they changed R1 regularly and that is why caregivers notified the administrator that R1’s wound was worsening. This lead to R1 going to the emergency room for an evaluation on 7/24/19 when R1 was diagnosed with a Stage III pressure injury. Interviews conducted with family members of other residents also did not corroborate the allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

A telephonic exit interview was conducted with Leticia Flores, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7