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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 11/28/2022
Date Signed: 11/28/2022 03:26:00 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
10/28/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221028082245
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: 74DATE:
11/28/2022
UNANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Susan Park/S-1TIME COMPLETED:
12:19 PM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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This report supersedes the complaint investigation report created on 11/03/2022 due to the initial report containing client confidential information (diagnostic). No other changes have been made to the report.

On 11/03/2022, Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial visit to investigate the above allegation. LPA met with Susan Park and explained the purpose of today's visit.

During this visit, LPA obtained a copy of the resident roster, staff roster, interviewed Staff #1 through Staff #3 (S-1 through S-3) and reviewed file for Resident #1 (R-1) and obtained copies of relevant documentation. R-1 is no longer residing at this facility. LPA attempted to interview R-1 via telephone at R-1's current location and was unable to interview as R-1 did not understand interview questions.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022
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 2
Control Number 28-AS-20221028082245
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GLEN PARK AT GLENDALE - MARIPOSA ST
FACILITY NUMBER: 197608506
VISIT DATE: 11/28/2022
NARRATIVE
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Allegation: Unlawful eviction. During this investigation, LPA interviewed S-1 through S-3 and reviewed R-1's file. LPA attempted to interview R-1 via telephone at R-1's current location and was unable to interview as R-1 did not understand interview questions. (2) out of (3) interviewed staff indicated R-1 was not evicted and indicated R-1 was sent to the hospital on 10/14/22 at 8PM (per physician order) for a psychiatric evaluation due to behaviors and not an evaluation to have R-1 placed in a "memory care". (2) out of (3) interviewed staff indicated staff were able to redirect R-1 and had R-1 participate in a Day Program during the week to keep R-1 engaged (to refrain from exhibiting behavior) and that it was manageable up until this recent hospitalization. (1) out of (3) interviewed staff was only involved in transferring R-1's belongings and was unaware of the reason why R-1 moved out. Per staff interviews, a family member for R-1 indicated that R-1 will be moving near Lancaster and requested that R-1's belongings be taken to R-1's hospital location. (3) out of (3) interviewed staff indicated they followed the family member's request, however, when R-1's belongings were taken to the new hospital location, the hospital location did not allow the items to be left. Therefore, staff returned back to this facility with R-1's belongings and family members came to the facility to retrieve the items. Staff interviews and documentation reviewed do not corroborate this allegation.

Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, appeal rights and a copy of this report was provided to Rachel De Chavez/S-2
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2