197802560-11-27-2023-28-AS-RORN-CY2LYD-20231129081006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 11/09/2023
Date Signed: 11/27/2023 10:18:49 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
10/30/2023 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231030113747

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: 41	DATE:	11/09/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Pam Ogot - Administrator		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Facility staff failed to assist resident with hygiene needs.
Staff did not prevent client from losing excessive weight.

INVESTIGATION FINDINGS:

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This is an amended report of original report dated 11/7/23, the purpose for amendment is to remove confidential information.This amended report does not change the findings.LPA Herrera redelivered report on 11/27/2023 and obtained signatures on the hard copy.

Licensing Program Analyst (LPA) Tena Herrera conducted unannocuned subsequent compliant visit to deliver findings pertaining to the above-mentioned allegations. LPA met with Administrator Pamela Ogot who also assisted with the visit.

(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: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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-20231030113747

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: 11/09/2023

NARRATIVE

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The investigation consisted of the following:
An initial 10-Day visit was conducted by LPA Herrera on 11/7/23.
During the visit LPA obtained copies of resident and staff roster, shower records/log, food menu, LPA observed meal being served for dinner and food menu. LPA obtained copies of Resident #1 (R1) files which included: admission agreement, needs and service plan, face sheet, ID and Emergency information, Resident Appraisal, Dietary Preference, Activity Program Information, doctors notes/summary, and medical records. LPA interviewed 5 Staff and 5 Residents during visit. (LPA later received a returned call from Staff # 5 (S5) and interview was conducted via telephone). It was determined that further investigation will be required and LPA will return at another time.

LPA reviewed food menu, observed dinner being served on visit dated 11/7/23 and toured kitchen which was observed with an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Interviews with 5 out of 5 residents stated they are fed 3 meals daily with snacks in between. During subsequent visit LPA attempted to interview R1's daughter via phone call and was not successful on both attempts. LPA interviewed R1 and obtained copy of Hospice Evaluation approval from R1's doctor.

The investigation revealed of the following:
Allegation: Facility staff failed to assist resident with hygiene needs.
It is alleged that staff have neglected to assist R1 with hygiene needs as it was stated that R1 was observed to have feces under fingernails and R1 was found in the shower alone, without assistance. Interviews with 6 out of 6 staff (whom work directly with R1) stated that R1 always rejects assistance with ADL's, R1 is a fall risk resident who ambulates with a walker. R1 does have incontinence management and often times refuses help with changing and cleaning and states "I can do it on my own", refusing to allow staff to properly assist, therefore, sometimes may have unsanitary fingernails. Staff all stated they have not seen R1 with feces under fingernails and always try to assist resident with all ADL's. S1 and S4 stated that they assist R1 with nail clippings in efforts to avoid any feces under nails as R1 tends to try and clean self without the needed assistance. Staff stated that R1 will attempt to bathe and clean self regularly and refuses help. S4 stated that on one occasion during rounds found resident attempting to bathe self and was able to redirect R1, explaining that staff is there to assist to ensure safety of R1 and was allowed to assist with R1 with shower. (Continued on 9099-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20231030113747

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: 11/09/2023

NARRATIVE

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Based off review of shower log R1 is assisted with baths 3-4 times weekly. Based off interviews with residents 5 out of 5 residents stated that staff assist with their hygiene needs on a frequent basis and have no complaints. Residents also stated that they have never been left unattended while being assisted with showers. Interview with R1, resident stated that they are offered assistance frequently but are not in need of any assistance and can do all things on their own. LPA observed resident to be in good spirits, well groomed with clean clothing and clean hands/fingernails.

Allegation: Staff did not prevent client from losing excessive weight.
It is alleged that R1 is "is dishelved and has lost weight". Based off weight record and interview with S6, R1 has lost a significant amount of weight from October 2023 to now. All other months Jan 2023 - Sept 2023 showed steady weight records with no dramatic changes. Doctors visits held in September and early October indicated no dramatic weight loss. S6 stated that R1's doctor and family were notified of the weight loss and the cause of the weight loss is still under review. S6 stated that they are working closely with R1's daughter to admit R1 to facility with higher level of care and are in progress of receiving hospice care for R1. Hospice Care was to assess R1 for services on 11/7/23, however, R1 was experiencing severe arm pain and was sent to the hospital for evaluation.The assessment has now been rescheduled for a later date. Interviews with staff 6 out of 6 staff stated that although they have noticed that resident has dropped a bit of weight, R1 does have a great appetite and eats their 3 meals and snacks daily. During interview with R1, resident stated that they have eaten breakfast and are about to eat lunch soon. R1 stated that they are provided 3 meals and snacks at facility and enjoy the food served. Interviews with 6 out of 6 residents indicated that they are provided with 3 meals daily and snacks in between.

Based on statements and interviews conducted with staff and residents and review of R1 files, 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: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC9099 (FAS) - (06/04)

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