197608506-6-22-2021-28-AS-MVAO-C6FRTH-20210901131822

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 06/21/2021
Date Signed: 06/22/2021 09:47:38 AM

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
04/28/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210428141835

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: 65	DATE:	06/21/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Rachel de Chavez		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for a resident while in care
Staff did not address a resident's change in medical condition while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegations listed above. LPA Spencer was met by assistant administrator Rachel de Chavez and explained the purpose of today's visit.

The investigation consisted of the following: On the initial investigation on 5/5/21, LPA Spencer took a tour of the physical plant, interviewed staff #1-2(S1-S2), residents #1-2 (R1-R2). On today's visit, LPA Spencer interviewed residents #3-6 (R3-R6), staff #3-4 (S3-S4). LPA received and reviewed copies of the staff roster, resident roster and R1's physician's report, needs and services plan, hospital discharge papers, hospital discharge checklists, and incident reports sent from the last 30 days.

***See LIC9099C for continuation of this narrative.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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-20210428141835

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: 06/21/2021

NARRATIVE

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The investigation revealed the following:

It was alleged that on 4/22/21, S4 did not call paramedics after R1 requested and refused to address the resident's change in condition. A review of R1's physician's reports and needs and service plan shows that R1 has a primary diagnosis of diabetes and blurred vision. The hospital discharge papers shows that the resident is frequently in and out of the hospital due to these concerns. A review of the incident reports for R1 shows that he was sent to the hospital on 4/18/21, 4/22/21, 4/24/21, 4/28/21, and 5/3/21 and the visits were due to weakness, dizziness, and hyperglycemia.

During interviews, R1 stated that he requested to go to the hospital but S4 refused and told him to wait until the facility nurse came in the morning. R1 stated that, due to staff's refusal, he had to ask R2 to use his phone so that he could call 911 himself. R2 stated that R1 knocked on his door asking for orange juice and to use his phone to call 911. R2 stated that R1 never mentioned that staff did not call 911 for him, but that he just requested orange juice and to use his phone. S4 stated that R1 only requested orange juice and never asked him to call 911. S4 responded to R1's request by checking his file to make sure he could have orange juice and told him to hold on a moment. He stated that R1 immediately left and was unaware that he wanted to call 911. According to the incident report dated 4/22/21, R1 made an internal complaint against S4, stating that he refused to call 911 when he requested it. S4 denied that he refused to call 911 and said that the resident only requested orange juice. S1-S4 stated that staff always call paramedics when residents request it. S1 stated that the staff did not call because the paramedics were already called by the resident. 3 out of 6 residents stated that staff seek timely medical care and address a change in medical condition for residents.

Based on interviews and records reviewed the findings show that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with the assistant administrator and copy of report was provided via email.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC9099 (FAS) - (06/04)

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