197608506-5-24-2021-28-AS-MVAO-C4FMCC-20210629092916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 05/24/2021
Date Signed: 05/24/2021 03:14:58 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
07/29/2020 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200729114420

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:	05/24/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Marina Pink (Administrator) and Rachel De Chavez (Assistant Administrator)		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Lack of supervision resulting in resident sustaining multiple falls
Facility staff did not seek medical attention in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with Maria Pink (Administrator) and Rachel De Chavez (Assistant Administrator) and discussed the purpose of today's visit. The initial visit was conducted on 08/05/2020.

On 08/05/20, at approximately 2:15 P.M., LPA Irra interviewed Ms. Flores and obtained revelant documentation.

During today's visit, LPA interviewed Maria Mullen (Med Tech), Ingrid Garcia (Caregiver) and Elizabeth Lacayo (Caregiver). LPA was unable to interview Resident #1 through Resident #3 (R-1 through R-3) as they are no longer residing at this facility. LPA interviewed Resident #4 through Resident #6 (R-4 through R-6).

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

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-20200729114420

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: 05/24/2021

NARRATIVE

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Allegation: Lack of supervision resulting in resident sustaining multiple falls. During this investigation, LPA obtained relevant documentation and interviewed Staff and Residents. Staff interviews revealed there is sufficient staff supervision. Staff interviews revealed that staff conduct rounds every (2) two hours and as needed throughout the entire day. Interviewed staff indicated rounds are documented with the resident’s names, dates, times and staff conducting the rounds. Interviewed Staff indicated they could not recall if R-3 fell at this facility while residing here. R-3 has not resided at this facility since 07/28/2020. R-3 documents indicate R-3 has a history of falls and requires assistance in Activities of Daily Living. Per Staff interviews, R-3 utilized a wheelchair. Interviewed staff indicated they have not received any complaints nor concerns in regards to residents falling from any resident representatives/family members, staff nor residents. LPA was unable to interview R-1 through R-3 as they are no longer residents at this facility. LPA interviewed R-4 through R-6 as they are considered to be a “fall risk”. Interviewed Residents indicated staff conduct rounds often throughout the entire day. Interviewed Residents indicated they have not fallen nor they have witnessed anyone falling. Staff and Residents interviews do not corroborate this allegation.

Allegation: Facility staff did not seek medical attention in a timely manner. During this investigation, LPA interviewed Staff and Residents. Interviewed Staff indicated the Med Tech completes an assessment to determine the type of medical attention a resident requires. Caregivers contact the Med Tech to complete the assessment. Interviewed staff indicated they have not had to request a Med Tech to assess any Residents for immediate medical attention as there has not been any emergencies during their shifts. Per reviewed documentation, R-3 was noted to be on a 2-hour checklist. R-3 sustained unwitnessed falls on 03/09/20, 07/05/20 and 07/26/20. For all incidents, staff had R-3 transported via ambulance to the hospital for additional assessments. Interviewed staff indicated they have not received any complaints/concerns from any resident representatives/family members, staff nor residents in regards to staff not seeking medical attention in a timely manner. LPA was unable to interview R-1 through R-3 as they are no longer residents at this facility. LPA interviewed R-4 through R-6 as they are considered to be a “fall risk”. Interviewed Residents indicated they have not needed nor have they witnessed any Residents needing immediate medical attention. Interviewed residents indicated staff seek for medical attention in a timely manner. Staff and Resident interviews do not corroborate this allegation.

**Refer to LIC 9099C for the continuation of this report***

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200729114420

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: 05/24/2021

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	Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report and Appeal Rights were provided to Ms. Pink

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC9099 (FAS) - (06/04)

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