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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608506
Report Date: 06/01/2021
Date Signed: 06/01/2021 05:24:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 STFACILITY NUMBER:
197608506
ADMINISTRATOR:PINK, MARINAFACILITY TYPE:
740
ADDRESS:1220 S MARIPOSA STTELEPHONE:
(818) 242-9000
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:120CENSUS: 65DATE:
06/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Marina Pink, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Linda Almaraz and Alberto Lopez conducted an annual required visit. LPA's met with Administrator Marina Pink and Officer Manager Leticia Flores and explained the reason for the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed residents' medications and observed food supply. Facility has submitted a mitigation plan and is pending approval.

The facility is a single story building. Common areas, including the living room, activity room and dining room appeared to be clean and properly furnished. The kitchen appeared clean and the appliances and fixtures are functional. There was a sufficient amount of perishable and non-perishable food at the facility. The medications were in the medication bins, properly labeled and stored. Medication documentation and implementation appeared to be complete. Facility has an isolation room available if needed. COVID-19 posters were posted at the entrance. Personal Protective Equipment (PPE) was adequate and available. Random resident rooms were inspected and observed with all required furnishings. Hot water temperature in random resident bathrooms were checked at an average of 117.3°F and within the required range.

No Deficiencies cited.
Exit Interview was conducted and a copy of the report was provided to Administrator.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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