197609007-5-28-2022-28-AS-SCOL-CF8PLE-20220609112436

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609007
Report Date: 05/28/2022
Date Signed: 05/28/2022 01:04:14 PM

Substantiated

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
10/06/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20211006153417

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:	05/28/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Violeta Necesito - Caregiver		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility did not provide resident's file to resident's responsible party.
Facility restricted resident's physical access to visits with family.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Violeta Necesito Caregiver and explained the reason for the visit. LPA reviewed report with Irene Deanon administrator over the phone.

The investigation consisted of the following: On 10/13/21 LPA Flores interviewed administrator, reviewed file for Resident #1(R1), and requested copies of Admissions Agreement, Hospital discharge and choice options form, Physician Orders for Life-Sustaining Treatment, Emergency Identification Information, Physician's Report, Needs and Care Plan, Power of Attorney, Hospice notes, Death report and Facility's Notes. On 5/23/22 LPA Flores contacted family member #3(F3). On 5/27/22 LPA Flores received via email visitation logs for February through May 2021.

(CONTINUED LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

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 3

Control Number 28-AS-20211006153417

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: 05/28/2022

NARRATIVE

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The investigation revealed the following: Regarding allegation: Facility did not provide resident's file to resident's responsible party. It is alleged facility has not yet provided resident's file requested by responsible party. File review conducted for resident #1(R1) revealed R1 has a durable power of attorney notarized on March 16, 2017 which appoints family member #1(F1) and family member #2(F2) as the representative party. On 9/30/21 Responsible party requested a copy of R1's resident's file including care notes via email. Per administrator Irene Deanon an incident occurred in December 2020 and a new power of attorney was assigned which is why facility did not provide documents to family member #2. However, there is no additional or most current durable power of attorney for R1. Family member #3 clarify the incident but was not able to recall dates or if there was a most current power of attorney.

Based on LPA's observation and file review conducted the preponderance of evidence standard has been
met, therefore the above allegation(s) are found SUBSTANTIATED.

Regarding allegation: Facility restricted resident's physical access to visits with family. It is alleged family members were barred from physically visiting R1 within the last 71 days of R1's life. Documents reviewed revealed R1 was receiving hospice services on 5/13/21 and passed away on 5/25/21. Facility Visitation Logs revealed facility had no in person visitors on February and March 2021 and were assisting with FaceTime and Window visits by appointment. Logs for April and May 2021 show visitors log-in, R1 had visitors from Hospice Agency and Physical Therapy, no other visitors were observed. Administrator stated that due to COVID 19 guidelines family members were not visiting indoors but were assisting with window and FaceTime visits which were not logged in the visitor's login sheet. R1's file revealed note dated 3/11/21 in which facility notes directives from family member #3 restricting visitations for R1. POA notes family member #2 as R1's responsible party. PIN 21.17ASC dated March 19, 2021, Notes General Visitation Requirements for Licensees for any visitor entering the facility regardless of their vaccination status.

Based on LPA's observation and file review conducted the preponderance of evidence standard has been
met, therefore the above allegation(s) are found SUBSTANTIATED. Health and Safety Code Title 22, Division
6, Chapter 3 are being cited on the attached LIC 9099D.

Exit interview was conducted with Violeta Necesito Caregiver and a copy of the report, LIC 9099D, and Appeal Rights have been provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20211006153417

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/30/2022 Section Cited CCR 87468.2(a)(21)	1 2 3 4 5 6 7	87468.2(a)(21) Additional Personal Rights of Residents in Privately Operating Facilities:(a) ... residents in... residential care facilities ... shall have all of the following personal rights: (21) To consent to have their relatives ...visit during reasonable hours, privately, and without prior notice. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will certify in LIC9098 that will follow recommended guidelines regarding visitation by Community Care Licensing, or Department of Public Health and will submit certification by POC due date 5/30/22.
	8 9 10 11 12 13 14	Based on document review licensee did not ensure to allow visitor for R1, while R1 was on hospice which poses an immediate health, safety, or personal rights risk for persons in care.	8 9 10 11 12 13 14
Type B 06/03/2022 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	87468.2(a)(19) Additional Personal Rights of Residents in Privately Operating Facilities:(a) ... residents in... residential care facilities ... shall have all of the following personal rights: (19) To ....purchase photocopies of their records. Photocopied records shall be provided within two (2) business days... This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator is to provide a copy of R1's file to responsible party listed on POA by 5/30/22 and submit a copy of acknowlegment of receipt by POC due date 6/3/22 to the department.
	8 9 10 11 12 13 14	Based on document review licensee did not ensure POA responsible party for R1 received a copy of R1's file which poses a potential health, safety, or personal rights risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2022

LIC9099 (FAS) - (06/04)

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