197608506-3-22-2025-31-AS-NMAN-DFJUSB-20250408155003

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 03/22/2025
Date Signed: 03/22/2025 03:17:47 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20241210123911

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:	DATE:	03/22/2025
		UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Susan Park		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff are not ensuring oxygen machine works properly.
Due to lack of supervision, resident was left on floor for an extended period of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted a subsequentl complaint visit to the facility to investigate the above allegations. LPA met with Executive Director, Susan Park, and explained the reason for the visit.

---Staff are not ensuring oxygen machine works properly.

It was alleged that staff are not cleaning oxygen filter regularly. To investigate the allegation, on 12/18/2024, LPA interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. – 1:00p.m. During interviews with staff, all staff stated they are not skilled medical professionals, they call a third-party company deals with the oxygen tanks. Staff added they only change the nasal device once every 30 days and assist with tubes if they are tangled, if there are any kinks and other simple and non-technical assistance.
(CONT. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2025

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 31-AS-20241210123911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT GLENDALE - MARIPOSA ST	FACILITY NUMBER: 197608506
	VISIT DATE: 03/22/2025

NARRATIVE

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During interviews with residents, one (01) out of nine (09) residents stated staff are not cleaning filter regularly. All other interviewed residents stated they do not have issue with their oxygen filters.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

---Due to lack of supervision, resident was left on floor for an extended period of time.

It was alleged that the resident fell and was found on the floor for unknown duration of time before staff found the resident. To investigate the allegation, LPA interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. – 1:00p.m. On 03/22/2025, LPA reviewed the Department’s records which shows resident had a fall on 10/25/2024 and 11/15/2024, however, there was nothing that indicate resident was left for an extended time. During interviews with staff, all staff stated they check on residents every two (02) hours, respond to the call button within five (05) to ten (10) minutes and do not leave residents on the floor for an extended time. During interviews with residents, one (01) out of nine (09) residents stated staff doesn’t check on them frequently and left them on the floor for an extended time. Resident was unable to provide dates or identify alleged negligent staff. All other interviewed residents stated staff check on them about every two (02) hours and have not experienced being left on the floor for an extended time.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2025

LIC9099 (FAS) - (06/04)

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