197802560-1-23-2024-28-AS-RORN-D22QGL-20240201110944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 01/23/2024
Date Signed: 01/23/2024 02:16:43 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
01/02/2024 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240102094739

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:	01/23/2024
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Assistant Administrator Martha Rosas		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff did not seek medical attention for resident.
Facility staff did not notify resident's responsible person of wounds requiring medical attention.
Facility staff did not ensure that resident's grooming needs were met.

INVESTIGATION FINDINGS:

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*****This report superseads report dated 01/11/2024. The reason for superseading is to include missing additonal supportive information in the original 9099. No other changes have been made to the report. Investigation findings remain the same.*****

Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent unannounced visit to provide additional information to the report regarding the allegations listed above. LPA was greeted by Administrator Pamela Ogot and Assistant Administrator Martha Rosas, the reason for the visit was explained.

(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: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20240102094739

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: 01/23/2024

NARRATIVE

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The investigation included the following:
During initial vist conducted on 1/3/24 LPA obtained copies of Resident and Staff Rosters and copies of documents within Resident #1’s (R1) file including: Admission Agreement, Identification and Emergency Information, Current Physician's Report, Appraisal and Appraisal/Needs and Services Plan, Copies of Most Current Nursing Home Podiatrist Visits, Hospice Information and Communication Log. LPA toured R1’s room and observed R1 to be clean, well groomed and social.
During subsequent visit dated 1/11/24 LPA interviewed 5 Staff, 5 Residents, R1's Power of Attorney, and Hospice Staff. LPA also interviewed the Responsible Parties of the 5 Residents interviewed.

The investigation revealed the following:

Allegation: Facility staff did not seek medical attention for resident.
It is alleged that, "the resident's toes are "raw and bloody", "infected" and "toe nails are coming off", and that R1 was in need of wound care and facility failed to seek wound care to resident. Per interviews with R1’s family, upon visiting resident on 1/1/24 it was discovered that resident had wounds to right foot/toes and family were providing their own wound care for 3 consecutive days to resident until facility provided care. Per R1’s medical records and hospice nurse notes/shower logs dated 12/21, 12/26 & 12/28, R1 had a complete shower with no signs of injuries and/or signs of pain noted by staff. Per interview with R1's hospice nurse, treatment to feet began on 1/3/24 and have been monitored during each visit, injuries to toes/foot observed on 1/3 were minor and there were no signs of infection. LPA observed R1 during initial visit on 1/3/23 and resident had a bandage on foot and hospice nurse was assisting resident, during todays visit LPA interviewed R1 and resident stated that their foot got the proper care, can now wear socks and that caregivers and nurse have been treating their foot on a daily basis. Resident was observed to be wearing clean socks and shoes during visit. Interviews with staff 5 out of 5 staff stated that while assisting with ADL’s staff did not observe the wounds to R1’s feet prior to 1/3/24 but have since then been making sure wounds are being treated and have undergone an In-service training dated 1/3/24 that covered care and monitoring of R1’s right foot and toes. Interviews with residents, 5 out of 5 residents stated that they get the proper medical treatment and staff are helpful when they have any need for medical assistance.

(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: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20240102094739

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: 01/23/2024

NARRATIVE

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Allegation: Facility staff did not notify resident's responsible person of wounds requiring medical attention.
It is alleged that Responsible Party (RP) was not notified of wounds to R1’s feet or medical attention needed to residents’ feet. Per RP they were never notified of foot treatment needed for R1. Per staff interviews 5 out of 5 staff stated that they were unaware of R1’s foot condition prior to 1/1/24, facility contacted hospice regarding R1’s feet and hospice provided foot care to resident on 1/3/24, after it was brought to staffs attention by RP during a visit. Per hospice staff the injuries to feet were minor and did not need immediate medical treatment, per hospice attending nurses during visits dated 12/21, 12/26 & 12/28 there were there were no signs of foot treatment needed at that time therefore no contact to responsible party was given, per shower logs also dated same as visits "full showers were given and resident denied any pain".
Allegation: Facility staff did not ensure that resident's grooming needs were met.
It is alleged that R1’s grooming needs are not being met as R1 had allegedly been wearing the same clothing for 3 consecutive days and clothing is visibly dirty. LPA observed resident during initial visit and R1 was well groomed with clean clothing, during subsequent visit LPA observed resident to be well dressed, groomed with clean nails and clean clothing. Interview with R1, resident stated they were provided with a bath in the morning and are given baths regularly. Interviews with Staff 5 out of 5 staff stated that R1 often refuses baths, however, with redirection R1 will comply. Interviews with S1 and S2, both stated that R1 does receive hospice service in which they bathe resident 3 times a week along with baths (as needed) that caregivers provide resident with. Communication log with hospice indicated that hospice staff bathe resident 2-3 times a week. Interviews with Residents 5 out of 5 residents stated that they are provided with showers/baths regularly and all appeared to be well groomed, with clean clothing and clean hands. Additionally, LPA interviewed Responsible Parties of the 5 residents interviewed and 4 out of 5 stated that residents appear clean and well groomed during visits, with a majority of visits being unannounced, and that they have never had any concerns regarding the above allegation.

Based on statements and interviews conducted with staff, residents and their responsible parties, review of R1's file and hospice records/communication logs, 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 Assistant Administrator Martha Rosas.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

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