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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802560
Report Date: 07/09/2024
Date Signed: 07/09/2024 04:26:37 PM


Document Has Been Signed on 07/09/2024 04:26 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



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: 43DATE:
07/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:28 PM
MET WITH:Pamela Ogot - AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a complaint visit (Complaint Control # 28-AS-20240702104018). The purpose of this visit is to issue deficiency that was observed by LPA that is not part of the complaint allegations.

During this visit LPA observed that the medication administration record (MAR) for Resident #7 (R7) for July 2024 was documented improperly. Based on the incident report (SIR) reported on 7/02/2024, R7 became unresponsive while a family member was visiting and was sent to the hospital. R7 was since transferred to a different facility due to the need for a higher level of care. However, LPA observed that on July 2024 MAR, it showed that the medications were administered and signed by the staff from July 2-8, 2024 when R7 was away from the facility. Staff admitted to the mistake and corrected the MAR immediately.

Deficiency is noted on LIC 809D. Exit interview conducted and a copy of this report was provided to Pamela Ogot, Administrator.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/09/2024 04:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2024
Section Cited
CCR
87506(a)

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87506 Resident Records...(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff...
This requirement is not met as evidenced by:
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Administrator agreed to submit a plan of correction to avoid improper documentation of Medication Administration Record (MAR). Administrator to re-train staff on medication management and documentation.
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Based on interviews and review of documentation, R7's Medication Administration Record (MAR) for July 2024 is inaccurate. Staff initialed the medication log from July 2-8 2024 when R7 was hospitalized and has already left the facility which posed an immediate health and safety risk to residents in care.
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 A copy of the in-service training form along with topics discussed and signatures of staff present will be submitted to CCL/LPA by the POC due date.

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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: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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