197802560-7-6-2022-28-AS-MVAO-CGZVSV-20220805164206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 07/06/2022
Date Signed: 07/06/2022 12:22:33 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
06/16/2021 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210616095611

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: 34	DATE:	07/06/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Pamela Ogot-Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained an unexplained fracture while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegations and for the purpose of rendering the findings. LPA met with Staff #1-Receptionist Martha Ulibe who allowed entry into the facility and explained the reason for the visit. The administrator, Pamela Ogot arrived later and assisted with the visit.

The investigation consisted of the following: On 6/17/21, LPA Wong and LPA Lopez conducted an initial visit, which included a health & safety check of residents in care and a tour of the facility and no immediate safety concerns were observed. Staff and resident interviews were not conducted during the initial visit. The following documents were requested and obtained: Resident #1-#3(R1-R3) file documents including Physician's Report, ID/Emergency Information, Appraisal Needs and Services, Preplacement Appraisal Information, Function Admission Agreement and Incident Reports.

(See LIC 9099C continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

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-20210616095611

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: 07/06/2022

NARRATIVE

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The complaint was referred to the CCL IB investigation Unit and assigned to IB Investigator Brian Slatic for full investigation. IB investigator Brian conducted and completed the investigation which included interviews with the family members, responsible party, facility administrator, five facility staff and Resident#1 (R1)’s former roommate. IB Investigator Brian also obtained Hospital Record, hospice documents and shower records.

The investigation revealed the following: Allegation “Resident sustained an unexplained fracture while in care.” The investigation revealed that R1 was non-ambulatory and required the use of a wheelchair and required at least two staff members to transfer from the bed to the wheelchair. R1 sustained a fracture to the right femur and the facility reported that they were not aware of any falls or any other explanation for how R1 sustained the fracture. All direct caregivers denied any knowledge of a fall or any other event that could have caused R1’s fracture. Resident’s facility and hospital records were also reviewed during the investigation. Per review of hospital records, the emergency room doctor stated that the fracture was most consistent with a traumatic injury such as a fall and yet there was no evidence of a fall. Per review of the facility records, the resident did not have a history of falls. The resident’s facility doctor does document that the resident has severe osteoporosis, which would make the resident very susceptible to a fracture without a traumatic event.

Therefore, there’s no sufficient evidence to support the allegation of resident sustained an unexplained fracture while in care. Therefore, LPA finds the allegation to be UNSUBSTANTIATED

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur., therefore the allegation is UNSUBSTANTIATED.

An Exit Interview Conducted and a copy of the report and appeal right was provided to Administrator Pamela Ogot.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

LIC9099 (FAS) - (06/04)

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