197608506-5-25-2021-28-AS-MVAO-C3ZTYB-20210615150829

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 05/25/2021
Date Signed: 05/25/2021 02:42:39 PM

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
12/08/2020 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201208161443

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: 63	DATE:	05/25/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Marina Pink, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Wrongful eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan made a subsequent visit to render findings regarding the above allegation. LPA met with the Administrator, Marina Pink, and Assistant Administrator, Rachel De Chavez and explained the reason for the visit.

On 12/16/20, LPA Chan conducted an initial 10-day visit and did the following: Interviewed the Administrator and a staff, requested copies of the staff roster, resident roster, the Admission Agreement, and eviction notice pertaining to Resident #1 (R1). In addition, LPA later requested more documents pertaining to R1’s eviction and interviews were conducted with R1 and R1’s case workers.

The investigation revealed the following:
Allegation – wrongful eviction. It is alleged that resident is being evicted from the facility based on being a "harm to self and others" and has not been reappraised by any medical staff (before the eviction).

(Continue on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

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-20201208161443

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: 05/25/2021

NARRATIVE

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LPA Chan interviewed Administrator Marina Pink who stated that Resident #1 (R1) was served an eviction notice on 11/16/20 due to violating the house rules of “harming or threat to harm oneself or others”. After several self injurious behaviors, the Administrator felt that R1 needed to be at a facility where they can closely monitor R1. Administrator also stated that during the preadmission assessment of R1, there were no indications on the Physician’s Report nor the Individual Service Plan (ISP) that stated R1 had a history of self-harming behavior. The behavior was not reported by R1's social worker prior to admission and was not written on the ISP until a later date. Per Administrator, she would not have accepted R1 if it was known that resident had that behavior prior.

LPA Chan obtained copies of the Individual Service Plan (ISP) dated 3/26/20 and 9/23/20, Appraisal Needs and Services Plan, and the facility’s Internal Incident Reports from period of August – November 2020. According to the documents reviewed, the facility took appropriate steps to address R1’s self-harming behavior and were documented as they occurred. R1's Planning team met on 9/23/20 for the bi-annual meeting and addressed the “cutting” behavior”. This ISP report was acknowledged and signed by R1 which indicated that R1 was reappraised before the eviction notice was issued. R1 continued to exhibit the behaviors as documented on 10/19/20 and 11/4/20. After reconsideration and speaking with Community Care Licensing Manager, the Administrator later rescinded the eviction letter. R1 is still residing at the facility as of today and is doing much better.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “wrongful eviction”.

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.

An exit interview was held. A copy of this report along with the Appeal Rights were given to the Administrator.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

LIC9099 (FAS) - (06/04)

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