197609084-5-3-2021-28-AS-MVAO-C2WQQ6-20210511122149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609084
Report Date: 04/30/2021
Date Signed: 05/03/2021 04:05:43 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
08/28/2020 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20200828090333

FACILITY NAME:	PARKVIEW OF GLENDALE		FACILITY NUMBER:	197609084
ADMINISTRATOR:	APRIL J TAYLOR		FACILITY TYPE:	740
ADDRESS:	426 PIEDMONT AVE		TELEPHONE:	(925) 377-5197
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91206
CAPACITY:	0	CENSUS: 0	DATE:	04/30/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jonathan Berg - Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff failed to provide residents with a 60 day notice

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Johnathan Berg, the facility licensee.

The investigation consisted of the following: On 9/3/21LPA Flores conducted telephone interviews with licensee at around 11:30am, administrator, residents #1,#2,#3,#4,#5,#6, staff #1,2,3,4,5, and a video call which consisted of a review of food supply, physical plant, utilities. and rooms #12, #108, #132, and #139, water temperature in the room's restrooms was observed between 105 and 120 degrees farenheit. The LPA also requested copies of staff and resident rosters, admissions agreements, physician's reports, and emergency information sheet for 7 residents. On 4/29/21 LPA Flores conducted additionally interviews with residents #7,#8,#9 over the phone. LPA contacted licensee left a voice message requesting a copy of the 60 day notice letter provided to the residents to be email by end of day. On 4/30/21 LPA Flores spoke with the Licensee over the phone and confirm the 60 day notice letters were provided to the residents on 10/2/20.
(Continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

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 3

Control Number 28-AS-20200828090333

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: PARKVIEW OF GLENDALE	FACILITY NUMBER: 197609084
	VISIT DATE: 04/30/2021

NARRATIVE

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The investigation revealed the following: Regarding allegation: Staff failed to provide residents with a 60 day notice. It is alleged facility did not provide a notice to residents and have been told facility is closing its doors on 9/7/21. During interviews conducted on 9/3/21 and 4/29/21, 7 out of 9 interviews with residents reveal residents were not provided a 60 day notice letter notifying them of facility closure. Residents stated to have been notified verbally of closure and need of relocation either; the day resident was relocated, a week prior to residents being relocated, and/or around July and August of 2020. 1 out of 9 residents was not aware of the situation and 1 out of 9 residents interview requested LPA speak to family/ responsible party. Interviews with 5 out of 5 staff revealed that staff had been notified of facility closure due to renovations during a staff meeting held three months prior to LPA's initial visit to the facility on 9/3/21. On 4/29/21 LPA Flores interview with resident's family member revealed family was notify verbally of need to find a different facility prior to September 2020 they were provided a written 60 day notice in December of 2020, resident was relocated in November of 2020 to a different facility. Interview with an additional family member revealed to have been notified verbally of need to relocated month before the resident was relocated, family member does not remember when a written notice was received and/or if received when it was provided resident was relocated in August 2020. Facility email plan of closure to the department on September 11, 2020 and provided copies of 60 day notices for residents dated October 2, 2020 after the fact that residents had moved out. Facility had moved out a majority of the residents by 9/3/21 and there were 7 residents residing at the facility at the time of the visit. Facility has been closed as of December 3, 2020.

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 3.2 are being cited on the attached LIC 9099D.

Exit interview was conducted with Licensee Jonathan Berg, licensee over the phone and a copy of the report, LIC 9099D, and Appeal Rights has been provided via email to the Licensee for signature.

On 4/30/21 LPA Flores spoke with Administrator Jonathan Berg, who stated he will not be signing the report. LPA clarified that if the report was not send by 5/3/21; 12:00pm LPA will assume administrator refused to sign the report. LPA did not received sign report. Therefore, LPA final print and a copy of the report will be mail to the address provided for the licensee.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200828090333

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: PARKVIEW OF GLENDALE	FACILITY NUMBER: 197609084
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/29/2021 Section Cited HSC 1569.682(a)(2)	1 2 3 4 5 6 7	§1569.682 Transfer of resident upon forfeiture of license...of facility;...: (a) A licensee of a...residential care facility... shall, prior to transferring... to another facility...take all reasonable steps ..: (2) Provide each resident or the resident’s responsible person with a written notice no later than 60 days...	1 2 3 4 5 6 7	Facility is curretly closed. No further plan of correction needed. Deficiencies provided for the record.
	8 9 10 11 12 13 14	Based on interviews and records review, licensee did not provided a 60 day written notice to 10 out of 10 residents 60 days prior residents were relocated to a different facility.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

LIC9099 (FAS) - (06/04)

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