197608506-8-31-2021-28-AS-MVAO-C74MLC-20210922094206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 08/31/2021
Date Signed: 08/31/2021 01:48:20 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
07/16/2020 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20200716165452

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:	08/31/2021
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Leticia Flores, Assistant Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff handled resident in a rough manner resulting in injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint investigation visit regarding the allegation listed above. LPA was met by Assistant Administrator, Leticia Flores and explained the purpose of today's visit. Later during the visit, Administrator Marina Pink arrived.

The investigation consisted of the following: On 7/17/20, LPA conducted telephone interviews with Flores, and Staff #1-3. On 8/31/21, LPA interviewed Staff #4-6 and attempted to interview Staff #7 and Residents' #1 (1:1) Caregiver but was unable because Staff #7 was not at the facility and the 1:1 caregiver was no longer working at the facility. LPA contacted staffing agency for the residents 1:1 caregiver but was not able to reach anyone. LPA also interviewed Residents #1-7. Resident #1's and Staff #1 and 2 file was also requested.

The investigation revealed the following: On 7/11/20, an incident occurred at the facility were Resident #1 was getting the residents daily eyedrops from Staff #7 and the staff missed the eye drop when she was putting it on. (Continued on an LIC-9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

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-20200716165452

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: 08/31/2021

NARRATIVE

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It was alleged a staff member handled the resident in a rough manner resulting in a injury. Interviews conducted revealed the resident was combative the day Staff #7 tried to put on the eye drops and the staff tried to calm the resident down. Interviews with staff stated the staff member did not handle the resident in a rough manner and do not remember seeing any bruising or redness on the residents arms. Per staff interviews, the resident never stated Staff #7 handled the resident in a rough manner or was hit. On 7/17/20, the police arrived at the facility and spoke to the resident but no report was filed after speaking to the resident and Flores. Records reviewed showed the resident was never taken to the hospital or had any injury. Interviews revealed that the resident has a history of getting combative with new staff administering medication and will make false allegations because the resident gets upset. LPA also interviewed residents and all interviews stated they have never seen or have been handled rough by Staff #7 or any other staff.

Although the allegations 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 conducted with the Assistant Administrator and a hard copy was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC9099 (FAS) - (06/04)

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