197802560-8-15-2023-28-AS-DSIS-CVMUNW-20230913154433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 08/15/2023
Date Signed: 08/15/2023 01:55:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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 Tena Herrera

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: 39	DATE:	08/15/2023
		UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Pam Ogot - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff did not reappraise resident.
Facility staffing was insufficient to meet resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint investigation to deliver findings on the above-mentioned allegations. Upon arrival, LPA met with Pamela Ogot (Administrator) and explained the purpose of the visit.

The investigation consisted of the following: On 8/25/21 LPA Kruz Long conducted the inital visit and obtained a copy of the Staff schedule (June-August 2021), copy of the Resident Roster and reviewed/obtained a copy of Resident #1's (R1) 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 1-8 (R1-R8). During subsequent visit today LPA Herrera obtained copies of the following documents: Staff/Resient Rosters, Current Staff Shedule and Staff Schedule from Jun-Aug 2021,

(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN PARK AT MONROVIA	FACILITY NUMBER: 197802560
	VISIT DATE: 08/15/2023

NARRATIVE

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R1's Records: Physicians Report, Pre Appraisal, Appraisal Needs and Service Plan, House Call Medical Records, Hospital Records, Admission Agreement. LPA also interviewed 5 Additional Residents and 6 Staff.

The investigation revealed the following:
Allegation: Facility staff did not reappraise resident.
It is alleged that the facility did not appraise and/or reappraise R1 to determine their individual needs and services. Based on R1's record review it was observed that there was a Pre-Appraisal conducted for R1 on 7/26/19 and Re-Appraisals conducted on the following dates: 8/23/19, 8/25/20, and 7/1/21. R1 passed on 7/24/21 while on hospice care at Redell Pine Board and Care. Based on interviews with Staff 1 (S1) and Staff 2 (S2) the residents are reappraised yearly and as needed to ensure the facility is able to meet the needs of the resident.

Allegation: Facility staffing was insufficient to meet resident's needs.
It is alleged that no one at the facility was adequately monitoring and supervising R1. During record review of R1 it was observed that R1 did not have a one on one caregiver. Interview with S2 indicated that R1 was on 2 hour room checks or as needed. During investigation LPA reviewed staff roster, current staff schedule and staff schedule from June-August 2021. The review of scheduling and staff interviews (5 out of 6 staff interviews) indicated sufficient staffing is available. S1 and S2 indicated that the use of an agency is utilized in the case of a staff shortage or call outs. LPA interviewed R9-R13 today and LPA Kruz interviewed R1-R8 during initial visit and 12 out of 13 residents denied the above allegation. Although, some may have stated the facility could use some more staff (as personal preference) residents agreed that they are being cared for well and in a timely manner to meet their needs.

Based on observation, record review and interviews conducted with staff and residents, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Administrator Pam Ogot.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC9099 (FAS) - (06/04)

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