197608506-10-24-2022-28-AS-RORN-CL82AR-20221115161358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 10/24/2022
Date Signed: 10/24/2022 02:04:06 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
10/17/2022 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221017102430

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: 76	DATE:	10/24/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Staff / Darkis Giron Administrator / Susan Park		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility is retaliating against a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Darkis Giron and was later joined by the Administrator / Susan Park who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Facility is retaliating against a resident".

During today's visit, LPA interviewed the Administrator, the Assistant Administrator and Resident 1 (R1). Also, copies of the following documents were obtained and reviewed in reference to R1;
• Identification and Emergency Information • Physician's Report • Admission Agreement • Unusual Incident/Injury Reports • 30 Day Notice to Quit • Friendly Reminder/Final Written Order • House Rules
• Medical Reports from LA Downtown Medical Center (LADMC)

Please see LIC 9099C for additional information

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

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-20221017102430

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: 10/24/2022

NARRATIVE

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The investigation revealed the following;

Allegation: Facility is retaliating against a resident. The details of this allegation state that on 10/10/22, R1 told the Administrator that she would no longer clean the library, the living room and dining room and three days after, on 10/14/22, R1 received an eviction notice in retaliation.

During the interview with the Administrator and Assistant Administrator, LPA discovered that R1 was issued a Friendly Reminder/Final Written Order on June 15, 2022, for violating Facility House Rules/Facility Policies. The concerns listed on the Friendly Reminder included the following;

• Verbal or physical abuse directed toward other residents or staff • Use of profanity and offensive language • Violent or anti social behavior • Harming or threat to harm oneself or others • Refusal to store prescribed and over the counter medications with facility

According to the Administrator and the Assistant Administrator, R1 was issued a 30 Day Notice To Quit on 10/14/22, as a result of ongoing concerns for failing to comply with facility house rules and policies (based on the concerns listed above). The Administrator and Assistant Administrator both denied issuing the 30 Day Notice To Quit as a form of retaliation to R1. Statements obtained from interviews conducted were consistent and corroborated that R1 voluntarily cleaned the library, the dining room and living room and often cared for the facility birds. R1 was not required or asked by facility staff to clean inside the facility or take care of the birds. It was strictly voluntary on behalf of R1. During the interview of R1, R1 admitted to being verbally abusive, using profanity and offensive language towards staff and residents. R1 also admitted for failing to have facility staff store prescribed over the counter vitamins. During the file review of R1, LPA discovered that R1 was hospitalized at LADMC in July of 2022 for depression, and being verbally abusive and physically aggressive. Based on the information gathered, there is insufficient evidence to support the allegation of "Facility is retaliating against a resident" to be true.

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 and a copy of this report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC9099 (FAS) - (06/04)

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