197608506-1-26-2023-28-AS-NGID-CQJS9E-20230403134034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 01/26/2023
Date Signed: 01/26/2023 01:42:46 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2023 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 28-AS-20230117101259

FACILITY NAME:	GLEN PARK AT GLENDALE - MARIPOSA ST		FACILITY NUMBER:	197608506
ADMINISTRATOR:	SUSAN PARK		FACILITY TYPE:	740
ADDRESS:	1220 S MARIPOSA ST		TELEPHONE:	(818) 242-9000
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	120	CENSUS: 72	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	09:39 AM
MET WITH:	Rachel De Chavez		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident left the facility unattended

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. LPA met with the Assistant Administrator, Rachel De Chavez, and advised her of the complaint. It was reported that, on or around January 14, 2023, Resident 1 (R1) wandered out of the facility, unsupervised. Staff were not aware of R1's absence until R1 was brought back to the facility by law enforcement. LPA's investigation consisted of interviews, which were held between 9:45am to 10:45am, a physical plant inspection, that was conducted approximately between 10:45am to 11:30am, and record review, made between 11:30am to 12:30pm.

According to the assistant administrator and staff, both confirmed that R1 wandered out of the facility unsupervised on January 14, 2023. The facility was receiving some deliveries at the time of the incident. The delivery person, set their delivery boxes in front of the receptionist, causing a blind spot. R1 must've exited with the delivery person, unnoticed by staff. By the time staff was getting ready to file a missing

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (323) 981-1782
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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 3

Control Number 28-AS-20230117101259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT GLENDALE - MARIPOSA ST	FACILITY NUMBER: 197608506
	VISIT DATE: 01/26/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

person report, R1 was brought back to the facility by law enforcement. Assessment made, R1 had no noted injuries. R1 was referred to their primary physician for a reassessment for possible higher level of care.

A review of R1's record reveal that R1 exhibits confusion and disorientation. R1 also exhibits sundowning, wandering behavior and cannot leave the facility unassisted.

During the physical plant inspection, LPA Cava observed monitors at the front reception desk to view cameras that are installed in common areas and exits for staff supervision. The front door has a delayed fifteen (15) second egress.

Although there was sufficient staffing at the time of LPA's investigation and functioning cameras in place to monitor facility activities, based on the information obtained through interviews, record review and plant inspection, there was enough evidence to corroborate the allegation that the resident left the facility unattended. Therefore, the allegation is Substantiated. Citation issued on the 9099D. The assistant administrator was advised, appeal rights and a copy of this report given.

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (323) 981-1782
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230117101259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT GLENDALE - MARIPOSA ST	FACILITY NUMBER: 197608506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/02/2023 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	Basic Services: If a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal. This requirement was not met as evidenced by R1 wandering out of facility, unnoticed, and as a result had no	1 2 3 4 5 6 7	As POC, the facility will submit to the licensing agency a reassessment of R1 and an updated care plan to meet R1's needs. POC is due to the licensing agency no later than February 2, 2023.
	8 9 10 11 12 13 14	supervision. A review of R1's files reveal R1 has a wandering behavior and is unable to leave the facility unassisted. Although the resident returned to facility with no injuries noted, this posed a potential risk to the resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (323) 981-1782
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3