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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 12/08/2022
Date Signed: 12/08/2022 12:33:02 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
12/01/2022 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221201141010
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:
12/08/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Susan Park (Administrator)TIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Facility staff refused to accept resident back after hospital stay.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Susan Park (Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff/Resident rosters, Resident #1's (R#1) Physician's Report, 30 Day Notice to Quit and Medical Records. LPA also interviewed Staff #1 in the Activity Room and interviewed Skilled Nursing Social Worker via telephone.

In regards to the allegation: Facility staff refused to accept resident back after hospital stay. Interview with Staff #1 indicate R#1 was admitted to the hospital on 11/21/22 and was later transferred to a Skill Nursing facility on 12/02/22. R#1 returned to the facility on 12/05/22 from the Skilled Nursing facility and was not refused acceptance back to the facility. Review of medical records indicate R#1 was admitted to the hospital on 11/21/22. LPA verified with the Skilled Nursing facility Social Worker that R#1 was at the Skilled Nursing facility from 12/02/22 to 12/05/22. LPA observed R#1 is currently at the facility. Continue to LIC9099C.....
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
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-20221201141010
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: 12/08/2022
NARRATIVE
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Based on LPA's interviews, record review and observation, the investigation revealed: 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.

Exit interview conducted with Susan Park and a copy of this report provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2