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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 03/23/2023
Date Signed: 03/23/2023 12:05:20 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/21/2023 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230321144556
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:
03/23/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Pamela Ogot (Executive Director)TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Pamela Ogot (Executive Director) and explained the purpose of the visit.

During today's visit, LPA obtained and reviewed a copy of the Staff/Resident roster, Resident #1's (R#1) Physician Report, Appraisal Needs and Services Plan, Incident Reports and Hospital Records. LPA attempted to interview R#1, interview Staff #1 to #5 in the office and interviewed R#2 to R#5 in the office.

In regards to the allegation: Staff did not seek medical attention for resident in a timely manner. Per allegation details, an incident occurred with R#1 who required medical attention. Review of Incident Reports provided to the department indicate facility did seek medical attention for R#1. LPA interviewed Staff and verified that facility did seek medical attention for R#1 in a time manner. Interviews with 5 of 5 Staff indicate they did not observe R#1 to have displayed symptoms prior to the incident. Interviews with 4 of 4 Residents also indicate when medical attention is needed, the facility does seek medical attention at a timely manner. Continue to LIC9099C.....
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
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 2
Control Number 28-AS-20230321144556
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/23/2023
NARRATIVE
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Based on LPA's record review and interviews, the investigation revealed: 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 conducted with Pamela Ogot and a copy of this report provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2