197609007-8-16-2021-28-AS-CYEE-C7CVVE-20210930164612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609007
Report Date: 08/16/2021
Date Signed: 08/16/2021 01:38:11 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
08/06/2021 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210806170224

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: 5	DATE:	08/16/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Irene Deanon		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility did not provide resident's file to resident's responsible party.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Irene Deanon and Assistant Administror Evangeline Ursua and explained the reason for the visit.

The investigation consisted of: LPA conducted an interview with Administrator Irene Deanon and Assistant Administrator Evangeline Ursua at 11:00am -11:45am. LPA obtained copies of Staff and Resident Rosters, reviewed Resident 1's (R1) file and collected copies of the following documents from R1's file: Physician's Report for Residential Care Facilities for the Elderly (LIC602A) dated 03/04/20, Unusual Incident/ Injury Report (LIC624) dated 03/10/21, Identification and Emergency Information (LIC 601) and copy of R1's Durable Power of Attorney dated 3/16/17. LPA also conducted a telephonIe interview with R1's family member at approximately 10:00am.

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021

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-20210806170224

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: 08/16/2021

NARRATIVE

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Investigation revealed the following: Regarding allegation, Facility did not provide resident's file to resident's responsible party, it is alleged that facility staff did not provide R1's responsible party (RP) with a copy of R1's Needs and Services Plan and it is also alleged that facility staff have not responded to R1's RP request for copies of R1's file. Interview with both Administrator Irene Deanon and Assistant Administrator Evangeline Ursua revealed that they have not received a request from R1's RP for copies of any documents or a request for a copy of R1's resident file. Interview with R1's RP revealed that they had not made a formal written request for any copies of any documents pertaining to R1 or their facility file. R1's RP stated that they would follow proper protocol and make a formal written request to facility licensee/ administrator. Based on interviews conducted with Administrator Deanon, Assistant Administrator Ursua, R1's RP and LPA review of R1's file, there was not enough supportive evidence to concur with the reported allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Administrator Irene Deanon.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021

LIC9099 (FAS) - (06/04)

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