197609007-7-14-2021-28-AS-LHIS-C6VSAX-20210915134304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609007
Report Date: 07/14/2021
Date Signed: 07/14/2021 04:53:53 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
07/07/2021 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210707084421

FACILITY NAME:	GLENDALE GARDEN CARE HOME		FACILITY NUMBER:	197609007
ADMINISTRATOR:	DEANON, IRENE		FACILITY TYPE:	740
ADDRESS:	405 CHESTER STREET		TELEPHONE:	(818) 640-2912
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91203
CAPACITY:	6	CENSUS: 6	DATE:	07/14/2021
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Lyn Ursua		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility falsified documents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit in response to the above allegation. LPA met with Assistant Administrator, Lyn Ursua who allowed entry into the facility and assisted with today's visit.

In response to the allegation that the facility falsified documents, specifically that facility falsified responsible parties signature on the Appraisal Needs and Services Plan for Resident #1. The investigation consisted of interview with Resident #1 family member, Staff #1, and review of Resident #1's file. LPA Rea obtained a copy of Resident #1's Appraisal Needs and Services Plan dated 3/29/19 from resident #1's family member. Resident #1's family member stated that she did not sign the Appraisal dated 3/29/19. LPA Rea reviewed copy of Appraisal Needs and Services Plan dated 3/29/19 from Resident #1's file at the facility. LPA observed that the signature did not appear to match the signature on the copy provided by Resident #1's family member. Staff #1 stated that she does not believe that the facility falsified the documents. Review of other documents, observed in Resident #1's file, show that Resident #1's responsible party/family member signature was not consistent.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20210707084421

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: GLENDALE GARDEN CARE HOME	FACILITY NUMBER: 197609007
	VISIT DATE: 07/14/2021

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

Based on LPA's observations and interviews, investigation revealed: Although the allegation 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 allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator, Lyn Ursua.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2