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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802560
Report Date: 07/06/2022
Date Signed: 07/06/2022 12:23:27 PM


Document Has Been Signed on 07/06/2022 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MONROVIAFACILITY NUMBER:
197802560
ADMINISTRATOR:ACHARYA, NIRJARAFACILITY TYPE:
740
ADDRESS:110 N MOUNTAIN AVETELEPHONE:
(626) 357-6818
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:49CENSUS: 34DATE:
07/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Pamela Ogot TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Christine Wong made an unannounced case management visit to cite for deficiencies related to complaint investigation control # 28-AS-20210616095611. LPA met with Administrator Pamela Ogot and discussed the purpose of the visit.

On the initial complaint visit conducted on 06/17/2021, a health & safety check of residents in care and tour of the facility and no safety hazards were observed. Staff and resident interviews were not conducted. Administrator Pamela Ogot provided LPAs copies of requested documents. The following documents were obtained: Resident #1-#3(R1-R3) file documents including Physician's Report , ID/Emergency Information, Appraisal Needs, Preplacement Appraisal Information, Function Admission Agreement and Incident Reports.. The complaint was accepted by the CCL IB investigation Unit, and assigned to IB Investigator Brian Slatic. IB investigator Brian conducted and complete investigation which includes interviews with the resident’s son/Health Care POA, facility administrator, five facility staff and Resident#1 (R1)’s former roommate. IB Investigator Brian also obtained Hospital Record, hospice documents and shower records.

During the investigation, IB Investigator Brian reported that facility staff were aware of R1 was experiencing leg pain and swelling as early as the afternoon of June 3rd, 2021. On June 4th 2021, R1's primary physician also advised to get R1 to the hospital. However, the facility failed to get R1 to the hospital through Emergency Medical Services (EMS) or a non-emergency ambulance service until the morning of June 5th, 2021 which facility failed to get R1 timely medical care and when the fracture femur was finally diagnosed.

Per Title 22, Division, 6, Chapter 8 has been cited. See LIC 809D.

Exit interview was held with Administrator. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2022 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2022
Section Cited

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87469 87469 Advanced Directives and Requests Regarding Resuscitative Measures(c)If a resident who has an advance.......... experiences a medical emergency (3) Specifically for a terminally ill resident that is receiving hospice services ............ For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).
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The requirement is not met by evidenced by interviews and record review, the facility staff did not call 911 until June 5th, 2021 and resident was complaining pain since mid afternoon of June 3rd and even doctor advised to send R1 to hospital which posed an immediate risk to residents in care.
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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