197608506-12-19-2022-28-AS-MVAO-CMKUNA-20221229144336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 12/19/2022
Date Signed: 12/19/2022 02:26:49 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
12/12/2022 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221212111200

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: 73	DATE:	12/19/2022
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Administrator Susan Park		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon 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 (R1) Physician's Report, Medical Records, three 5150 hold evaluation reports and Unusual Incident reports (UIR) on R1 hospital transportation and R1 Admission Agreement. LPA also interviewed Administrator and Staff #1 (S1) in the Activity Room and attempted to interview R1 via telephonically and was not successful.

In regards to the allegation: Illegal Eviction. Based on record review and supportive documentation provided indicate R1 was admitted and placed on a 5150 hold on 12/09/22 and transferred to the hospital. Based on record review of R1 Physician Report states R1 type of medical supervision needed is to be placed in a Skilled Nursing Home. Continue to LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022

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-20221212111200

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: 12/19/2022

NARRATIVE

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Interview with Administrator and S1 stated denied no new eviction letter was given to R1 written or verbally. LPA Calderon reviewed R1's file and no eviction letter was observed. Interview with Administrator stated R1 told hospital that R1 refuses to be transported anywhere else that isn't the above facility. R1 remains in the hospital until further notice and until R1 is placed in a facility that is appropriate for the level of care R1 is required to have based on doctors reports. Facility will provide Discharging Planner information on Skilled Nursing Homes for R1 proper placement based on R1's needs.

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 Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022

LIC9099 (FAS) - (06/04)

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