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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:12:55 AM

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
10/18/2022 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221018112737
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: 76DATE:
10/31/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Susan Park- AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Unlawful eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of delivering findings for the complaint regarding the above-mentioned allegations. LPA Maldonado met with Administrator Susan Park and explained the purpose for the visit.

On 10/20/22, LPA Maldonado made an initial visit to the facility for the purpose of investigating the above-mentioned allegations. During the visit, LPA reqested a copy of the resident and staff roster, and the Facesheet and Physician's Repor for Residents# 1-7 (R1-R7). LPA also requested copies of the following documents for R1: Psychiatric Evalutions and Incident Reports for the months of March 2022-October 2022, Eviction Notice, Copy of House Rules, and written warning of possible eviction. The following documents were obtained for Staff# 1-3 (S1-S3): Personnel Records and Required Training Certification. Interviews were conducted with R1-R7 and S1-S3.

(Report Continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
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 6
Control Number 28-AS-20221018112737
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: 10/31/2022
NARRATIVE
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The investigation revealed the following:

Regarding allegation: Unlawful Eviction.
It is alleged that R1 is being evicted for violent or anti-social behavior, harassing to threaten or harm others, and refusing to store over the counter medication. LPA obtained a copy of the 30-day Notice of Eviction, which states that R1 violated House Rule #13, which includes "Violent or Anti-Social Behavior, harming or threat to harm oneself or others, and refusal to store prescribed and over the counter medications with facility." During interviews conducted with S1-S3, (3) of (3) staff stated that R1 is constantly cursing at the facility staff for any reason. R1 threatens to hit staff, but has never physically hit staff or other residents. During interviews conducted with R1-R7, (6) of (7) residents have witnessed R1 yelling and cursing at staff when she is upset. (6) of (7) residents witnessed R1 arguing with one other resident in the past, but stated they never saw R1 become physically aggressive with any resident or staff. R1 admitted to yelling and cursing at the staff due to them not keeping the facility clean the way she wants it or for caring for the facility birds the way she would like to. R1 also admitted to yelling at one other resident before because R1 did not get along with them. After review of the Facility House Rules, it was determined that the house rules may be violating resident's personal rights and the grounds for eviction for which R1 has been given a 30-Day written notice are unlawful. Therefore, this allegation is substantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated.

Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D.

An exit interview was conducted with administrator Susan Park and copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20221018112737
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: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2022
Section Cited
CCR
87224(a)(3)
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87224 Eviction Procedures
(a) The licensee may evict a resident... Thirty (30) days written notice to the resident is required.(3)Failure of the resident to comply with general policies of the facility... general policies must be in writing... for the purpose of making it possible for residents to live together and must be made part of the admission agreement.
This requirement if not met as evidenced by:
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Licensee will rescind the 30-day writen notice and the Behavior Contract signed by the resident. A written notice of the rescinded notices will be emailed to LPA by the POC due date.
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Based on interviews and records review, the licensee issued an eviction notice based on house rules that include verbal abuse directed towards staff, which is not a reason for eviction, per eviction procedures. This poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
10/18/2022 and conducted by Evaluator Valeria Maldonado
COMPLAINT CONTROL NUMBER: 28-AS-20221018112737

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: DATE:
10/31/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Susan Park- AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff are threatening resident.
Staff are making inappropriate comments towards resident.
Staff forced resident to eat in the library.
Staff did not safeguard residents personal belongings.
Staff are not properly cleaning the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of delivering findings for the complaint regarding the above-mentioned allegations. LPA Maldonado met with Administrator Susan Park and explained the purpose for the visit.

On 10/20/22, LPA Maldonado made an initial visit to the facility for the purpose of investigating the above-mentioned allegations. During the visit, LPA reqested a copy of the resident and staff roster, and the Facesheet and Physician's Repor for Residents# 1-7 (R1-R7). LPA also requested copies of the following documents for R1: Psychiatric Evalutions and Incident Reports for the months of March 2022-October 2022, Eviction Notice, Copy of House Rules, and written warning of possible eviction. The following documents were obtained for Staff# 1-3 (S1-S3): Personnel Records and Required Training Certification. Interviews were conducted with R1-R7 and S1-S3.

(Report Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20221018112737
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: 10/31/2022
NARRATIVE
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The investigation revealed the following:
Regarding allegation: Staff are threatening resident.
It is alleged that the facility administrator told R1 that if R1 did not turn in their over the counter medications to the facility staff for storing, they would evict R1. During interviews conducted with R1-R7, (6) of (7) residents have no knowledge of a resident being threatened by facility staff. During interviews with S1-S3, (3) of (3) staff denied ever threatening a resident in care and have no knowledge of other staff threatening residents in care.
Regarding allegation: Staff are making inappropriate comments towards resident.
It is alleged that facility staff told R1 that if R1 is good to the facility staff, they will also be good to her- regarding R1's notice to the administrator that R1 will no longer continue their voluntary assistance with cleaning the facility. (6) of (7) residents interviewed stated staff have never made inappropriate comments toward them and have no knowledge of staff making inappropriate comments to other residents in care. (3) of (3) staff interviewed stated denied ever making inappropriate comments to any resident in care. Staff state R1 is the one making inappropriate comments to staff and residents.
Regarding allegation: Staff forced resident to eat in the library.
It is alleged that R1 was forced, by the facility administrator, to eat in the library for the past 6 months, due to R1 not getting along with 2 other residents. R1 admitted to not getting along with 2 residents; However R1 stated that R1 was given the option to eat there alone. R1 stated to prefer it, up until now. (3) of (3) staff denied forcing residents to eat in the library. Staff interviewed stated R1 was given the option to eat there and preferred it until now. R1 has requested to return to eat in the dining room with the other residents. (6) of (7) residents interviewed stated they are unaware of residents being forced to eat in the library.
Regarding allegation: Staff did not safeguard residents personal belongings.
It is alleged that staff are going to R1's room and going through R1's makeup and breaking R1's lipsticks. (3) of (7) residents interviewed stated some of their personal belongings went missing. They brought it to the attention of the administrator and staff stated to have conducted an investigation, but their missing things were never found. (3) of (3) staff interviewed stated they have no knowledge of resident's personal belonging being lost or damaged by other staff or residents.




(Report Continued on LIC9099-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20221018112737
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: 10/31/2022
NARRATIVE
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Regarding allegation: Staff are not properly cleaning the facility.
It is alleged that staff do a sloppy job with putting towels on the rack, throwing trash away and not putting the trash bag in the can correctly. (6) of (7) residents interviewed stated they have no issues with the cleanliness of the facility. They state staff do a good job at maintaining the facility clean. LPA observed common areas, walkways, hallways, offices, and resident rooms to be clean and free of obstruction and hazards. (3) of (3) staff stated that although R1 insisted on cleaning the facility birds and some areas of the facility, R1 was told often to not clean because that is staff responsibility; However R1 continued to do so. R1 admitted to cleaning because R1 liked certain things to be cleaned in a particular way.

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 is Unsubstantiated.

An exit interview was conducted with Administrator Susan Park and a copy of the report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6