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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 02/22/2024
Date Signed: 02/22/2024 01:27:52 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
02/15/2024 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240215122633
FACILITY NAME:GLEN PARK AT MONROVIAFACILITY NUMBER:
197802560
ADMINISTRATOR:ACHARYA, NIRJARAFACILITY TYPE:
740
ADDRESS:110 N MOUNTAIN AVETELEPHONE:
(626) 357-6818
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:49CENSUS: 42DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Martha Rosas - Assistant AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff are inappropriately administering medications to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analsyts (LPA) Tena Herrrera conducted an unannounced initial complaint visit in regards to the allegation listed above. LPA met with Assistant Administrator Martha Rosas and explained the purpose for todays visit.

The investigation consisted of the following:
LPA obtained copies of both Staff and Resident Rosters, SIR submitted to licensing on 1/22/24 with discription of alleged incident, Copies of Resident #1's (R1's) Physician Report, Police Report Number (for alleged incident), Discharge Paperwork from hospital dated 1/18/24, follow up visits with R1's physicians post incidnet; R2's Physician's Report, R2's Special Medication Order and copies of the staff in-service training that was held on 1/23/24 covering Resident ADL's, including Medication Administration. LPA also interviewed 4 staff and 5 residnets.
(Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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 5
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
02/15/2024 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240215122633

FACILITY NAME:GLEN PARK AT MONROVIAFACILITY NUMBER:
197802560
ADMINISTRATOR:ACHARYA, NIRJARAFACILITY TYPE:
740
ADDRESS:110 N MOUNTAIN AVETELEPHONE:
(626) 357-6818
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:49CENSUS: 42DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Martha Rosas - Assistant AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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9
Staff mismanages residents' medications.
INVESTIGATION FINDINGS:
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Licensing Program Analsyts (LPA) Tena Herrrera conducted an unannounced initial complaint visit in regards to the allegation listed above. LPA met with Assistant Administrator Martha Rosas and explained the purpose for todays visit.

The investigation consisted of the following:
LPA obtained copies of both Staff and Resident Rosters, Special Incident Report (SIR) submitted to licensing on 1/22/24 with discription of alleged incident, Copies of Resident #1's (R1's) Physician Report, Police Report Number (for alleged incident), Discharge Paperwork from hospital dated 1/18/24, follow up visits with R1's physicians post incidnet; R2's Physician's Report, R2's Special Medication Order and copies of the staff in-service training that was held on 1/23/24 covering Resident ADL's, including Medication Administration. LPA also interviewed 4 staff and 5 residnets.
(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240215122633
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: 02/22/2024
NARRATIVE
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The investigation revealed the following:
Allegation: Staff mismanages residents' medications.

It is alleged that staff mismanages residents medications as R1 accidentally consumed food that contained medication belonging to R2 and was thus sent to the hospital because of this incident. Per Staff interviews it was determined that during medication administration Staff #3 (S3) placed crushed medication in food for R2 and R1 grabbed the food and ate some of it. S3 immediately let front staff know of incident and 911 was called, ambulance arrived and transported R1 to hospital for cleansing and observation and returned to facility same day, all responsible parties were notified and an SIR was submitted to licensing. Facility provided R1 with all follow up appointments following the incident. After medical record review it was found that R2 has a physicians order stating that medication of R2 is able to be sprinkled in food and consumed. S1 stated that an in-service training was conducted after this incident and covered medication administration, S1 provided LPA with a copy of the In-Service training log with participant signatures and training materials. During interview with S3, staff confirmed in-service was conducted after incident covering the medication administration and that they attended the training. LPA reviewed 5 resident medications during visit with no issues observed. LPA interviewed 5 residents and 5 out of 5 residents stated that they are provided medication at the facility and have never experienced staff mismanaging their medication. During interview with R1, resident stated they didn't know that there was medication in the food, went to the hospital right after and had follow up visits with their doctors after the incident.

Based on LPA's observations and interviews which were conducted, and resident record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held, and a copy of this report and appeal rights was provided to Assistant Administrator Martha Rosas.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20240215122633
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
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Administrator/Licensee to conduct a training in medication management and medication administration. Copies of Training and Training Log with Participants to be provided to LPA. **incident took place on 1/18/24 and facility held staff training on 1/23/24 - all copies of taining were provided to LPA during visit**
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This requirement is not met as evidenced by: During investigation it was found that the alleged incident did occur as R1 ate food that contained medication that was prescribed to R2 in error.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240215122633
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: 02/22/2024
NARRATIVE
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The investigation revealed the following:
Allegation: Staff are inappropriately administering medications to residents.

It is alleged that staff are inappropriately administering medications to residents by placing medication in residents food. What was witnessed was R2 being administered medication on food and R1 then taking the food and consuming it when staff was not looking. Per record review R2 has a doctors order in which staff administering medication are granted permission to crush medication and sprinkle on food for taste. Facility followed protocols by calling authorities, ambulance, reporting parties and notifying licensing, R1 was taken to the hospital for observation and treatment if needed and facility followed up with primary physician's once R1 returned to the facility. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that all medication is administered per doctors orders and is documented in the Medication Administration Record (MAR). Interview with S3, staff stated that the above incident did occur, however, medication was being administered to to correct resident but R1 took the food not knowing there was medication in it. LPA interviewed 5 residents and 5 out of 5 residents stated that they feel staff are giving them their medication properly and have not been administered medication from another resident. Interviews with residents stated that staff announce what the medication is and what it is for while administering medication. LPA reviewed 5 Resident medications during todays visit and there were no issues observed. Although medication was consumed by the incorrect resident (which this error is being addressed on a 9099-A), there was no evidence found to support the above allegation.

Based on statements and interviews conducted with staff and residents, and review of resident records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Assistant Administrator Martha Rosas.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5