197802560-8-25-2021-28-AS-DSIS-CVMUNX-20230913154433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 08/25/2021
Date Signed: 08/25/2021 02:47:06 PM

Unsubstantiated

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
08/16/2021 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210816095011

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: 29	DATE:	08/25/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Pamela Ogot (Administrator)		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff did not notice a change in the resident's condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Pamela Ogot (Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff schedule (June 2021-August 2021), a copy of the Resident Roster and reviewed/obtained a copy of Resident #1's records (Physician's report, Appraisal/Needs and Services Plan, Preplacement Appraisal Information, Weight Chart, Resident Appraisal, Functional Capability Assessment, House Call Medical Records, Hospital Records and the Admission Agreeement). LPA also interviewed Residents #1 to #8 in the Administrator's office between 12:00 pm to 12:40 pm.

Continue to LIC9099C......

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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-20210816095011

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: 08/25/2021

NARRATIVE

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In regards to the allegation: Facility staff did not notice a change in the resident's condition. Based on the review of Medical Records (HouseCall MD, Inc.) which indicate from 12/12/19 through 06/04/21, in house medical services were provided to Resident #1 on a monthly or as needed basis. Medical Records documented Resident #1's medical history and assessment plan, therefore facility was aware of any changes in Resident #1's medical conditions.

Based on LPA's record review, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with Martha Rosas (Reception) and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC9099 (FAS) - (06/04)

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