197802560-10-26-2023-28-AS-DSIS-CWZSSY-20231027140843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 10/26/2023
Date Signed: 10/26/2023 09:58:25 AM

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
07/26/2021 and conducted by Evaluator Tena Herrera

COMPLAINT CONTROL NUMBER: 28-AS-20210726164431

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: 42	DATE:	10/26/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Martha Rosas - Assistant Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident sustained pressure injuries while in care.
Resident did not have care plan for pressure injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Martha Rosas (Assistant Administraor) and explained the purpose of the visit.

Investigation consisted of the following:

During the initial visit conducted on 07/28/21, LPA Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility LPA reviewed the file of Resident #1 (R1) and obtained copies of the following documents; Client Information Sheet, Admission Agreement , Agreements and Consent for Medical Treatment, Individual Program Plan (IPP), Unusual Incident/Injury Reports, Physician/Nurse Notes, Facility Progress Notes, Hospital Reports, Lab Results, Resident Roster and Staff Roster. Due to insufficient information available at the time, the allegations needed further investigation.

(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: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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-20210726164431

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: 10/26/2023

NARRATIVE

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Investigation revealed the following:

In regards to the allegations “resident sustained pressure injuries while in care” and “resident did not have care plan for pressure injuries”.

It is alleged that Resident #1 (R1) did not have a care plan for pressure injuries and therefore sustained pressure injuries while in care at the facility. This allegation was investigated by Investigator Brunelli with the Investigations Branch. R1 was diagnosed with Cerebral Palsy, history of epilepsy, and later non-ambulatory with contractures of arms and legs. R1 was admitted to facility and transferred to hospitals for wound care treatments from dates 2/18/21 – 7/20/21. Wounds would be treated and monitored at facility by home health. Based on interview with both hospitals Wound Care Ostomy Nurses and Home Health Care Nurses treating R1, all revealed the pressure injuries were not infected, looked healthy, small, and superficial and there were no concerns for abuse or neglect based on the pressure injuries. Based off of two hospital record reviews for R1, facility file review, interviews with both hospitals treating wound care nurses, interviews with family, interviews with treating home health care nurse, and previous medical history it was determined that it does not appear the care provider delayed in transferring R1 to a hospital for Skilled Nursing Facility (SNF) for wound treatment. Based off of record review and interviews with treating home health care nurse there was a wound care plan for R1 with a written order from the facility doctor with recommendations and a progress plan.

Based on statements and interviews conducted with staff and family, review of R1 files and medical records, there was not enough supportive evidence to concur with the reported allegations.

Although the allegation may have happened or is 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 Assistant Administrator Martha Rosas and Administrator Pamela Ogot.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC9099 (FAS) - (06/04)

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