197802560-6-13-2023-28-AS-ACAN-CSRU2E-20230613151150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802560
Report Date: 06/13/2023
Date Signed: 06/13/2023 03:11:56 PM

Document Has Been Signed on 06/13/2023 03:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 37	DATE:	06/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Assistant Administrator -Martha Rosas		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ashley Calderon conducted a site visit for the Required - 1 Year inspection using the CARE Tool. Upon arriving at the facility, LPA met with Assistant Administrator Martha Rosas and shortly after with Administrator Pamela Ogot. The facility is licensed to serve for a capacity of 49 residents (45 Non-Ambulatory and 4 Bedridden residents only) ages 60 and above. Bedridden residents are to be on the first floor only. The facility has an approved Hospice Waiver on file for eight (8) Residents. Approved Dementia Care Plan in their plan of operation and accepts residents with dementia. There is no separate memory care unit inside the facility. Currently there are 3 residents on Hospice/ 0 bedridden. LPA toured the physical plant with Martha. LPA observed areas inside and outside patios / gardens. The first level consists of a dining room, kitchen, activity room, medication room, multiple offices, lobby, laundry room and resident rooms. The second floor consist of resident rooms, an activity room, beauty shop and a community shower. The facility is equipped with cameras in the common areas of the facility. LPA toured a random selection of resident rooms on each floor. Rooms 1,7,11,210 and 214. Resident rooms were furnished appropriately. Each resident room has their own restroom. The bathrooms were observed to be clean and operational w/grab bars and non skid mats. The resident rooms have a signal systems located in each restroom and near bedside with intercom. The signal system was tested in various locations and is operable. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The facility has central air and heating accommodations located in the common areas and resident rooms are equipped with cooling and heating wall units. The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies and perishable food was stored in covered containers at the appropriate temperatures. Storage areas for cleaning solutions, toxins, knives, and hazardous items were secured and made inaccessible to residents. Continuation on 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/13/2023

NARRATIVE

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The fire extinguishers were observed throughout the facility and were fully charged and serviced. The carbon monoxide detectors are operable and in compliance. Smoke detectors were observed and tested throughout the facility and were operable. Pull Fire alarm system observed and connected to the City of Monrovia Fire Department. Fire and Disaster Drill: 6/7/23. LPA observed elevator out of order, company D&G Elevator Company contacted on 6/7/23, company inspected and waiting on parts.

The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. The outdoor area was enclosed and no large bodies of water were observed. Delayed egress devices in place.

Medications are centrally stored in the locked medication room located on the first floor and medication carts are maintained locked. LPA Calderon reviewed 5 residents medication(s) and medication book along side with Med-Tech Maria Galvan. No deficiencies notes.

LPA Calderon interviewed 3 residents and 3 staff. LPA reviewed a total of 5 resident files all had appropriate documentation. LPA reviewed 5 staff files, cleared and appropriate documentation in place. Facility had appropriate documentation's posted in the front areas near office(s).

Liability Insurance Expires: 12/5/23
Administrator Certificate for Pamela A Ogot Expires: 9/16/24

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to Staff / Martha Rosas and Administrator Pamela Ogot.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC809 (FAS) - (06/04)

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