197802560-7-12-2021-28-AS-SCOL-CCXLQ3-20220328085651

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 07/12/2021
Date Signed: 07/12/2021 02:30:10 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
06/07/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20210607140619

FACILITY NAME:	GLEN PARK AT MONROVIA		FACILITY NUMBER:	197802560
ADMINISTRATOR:	ACHARYA, NIRJARA		FACILITY TYPE:	740
ADDRESS:	110 N MOUNTAIN AVE		TELEPHONE:	(626) 357-6818
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	49	CENSUS: 33	DATE:	07/12/2021
		UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Pamela Ogot - Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not provide resident's records to responsible party upon request.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations.

The investigation consisted of the following: On 6/16/21 LPA Flores interviewed administrator, and requested copies of law firm's request of Resident 1's file (R1) letter, emails of communication with law firm, R1's Physician report, Appraisal/Needs and Care Plan, Identification and Emergency Information, Functional Capability Assessment. Admission Agreement, Admission Record, and Release of Client/Resident Medical Information. LPA was unable to interview R1, as R1 is at a Skill nursing facility. On 7/12/21 LPA Flores attempted to contact R1 at 8:15am, 12:20pm, 1:00pm 1:10pm.

The investigation revealed the following: Staff did not provide resident's records to responsible party upon request. It is alleged legal office requested records on behalf of R1 on 05/26/2021 and "as of today, no records have been produced." Interview with administrator revealed facility did not provided R1's copies of files (CONTINUED LIC9099C)

Unsubstantiated

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: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

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-20210607140619

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 MONROVIA	FACILITY NUMBER: 197802560
	VISIT DATE: 07/12/2021

NARRATIVE

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after facility's legal department review the petition and per policy facility is not authorize to provide the documents to a third party unless they are subpoena. During R1's file review LPA Flores observed R1 resided at the facility since 11/19/2019, and no longer resides at the facility. R1 was admitted to Arcadia Methodist Hospital on 1/11/21, transfer to Whittier Hospital Medical Center on 1/14/21, transfer to a higher level of care on 1/29/21, and R1 moved out of the facility on 2/11/21. R1's Identification and Emergency Information states R1 represents self, no power of attorney, or regional center involved. LPA observed and reviewed Legal Services requested R1 personal file on 5/26/21 via letter, attached a HIPAA Compliant Authorization for the Release of Patient Information Pursuant and Authorization to Handle Claim signed by R1 on 5/10/21. On 7/2/21 LPA Flores called R1 current residency 4 times in attempt to verify request of documentation with R1. LPA was not able to contact R1 left two messsage and call was not returned. Administrator visited R1 at higher level of care facility on May and there was no verbal request from R1 for personal file. Per California Code of Regulations (CCR) Title 22 it is a residents personal right to request a copy of their personal file which is to be provided to the resident within 2 days. Although R1 may have authorize legal services, facility is following CCR regulations and facility's legal department as the request is coming from a third party, not the resident, or power of attorney.

Based on documents review, and interviews the preponderance of evidence standard has been met, therefore the allegation(s) are found UNSUBSTANTIATED.

Exit interview was conducted with Pamela Ogot administrator and a copy of the report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

LIC9099 (FAS) - (06/04)

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