197802560-11-19-2024-28-AS-DSIS-DBLP5N-20241203100100

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 11/19/2024
Date Signed: 11/19/2024 05:54:44 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
11/18/2024 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241118093118

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: 45	DATE:	11/19/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Pamela Ogot - Executive Director Martha Rosas - Assistant Administrator		TIME COMPLETED:	02:36 PM

ALLEGATION(S):

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Staff did not ensure adequate supervision was provided, resulting in a resident being injured.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Pamela Ogot, Executive Director and Martha Rosas, Assistant Administrator and explained the purpose of the visit.

The investigation consisted of the following: LPA obtained copies of the Resident & Staff Rosters, Resident #1 (R1) files such as: Identification and Emergency Information (Face sheet), Admission Agreement, Physician's Report, Preplacement Appraisal, Personal Rights, Resident Appraisal, Hospital Release Records, Unusual Incident/Injury Reports (10/28/2024) related to the incident and Police report (24-0197771). LPA toured the facility's common areas including R1-R3's rooms and interviewed Staff #1 (S1) - Staff #6 (S6) and Resident #1 (R1) - Resident #7 (R7).

The investigation revealed the following:
In regards to the allegation: “Staff did not ensure adequate supervision was provided, resulting in a resident being injured.” It is alleged that on 10/27/2024 at around 2 AM, 2 staff were both on a break at the same time when R1 sustained injuries because he had wandered into another residents room and was struck with a cane by the resident during the altercation.***REPORT CONTINUED ON LIC9099-C***.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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-20241118093118

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: 11/19/2024

NARRATIVE

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6 out of 6 staff members interviewed denied the allegation. Staff interviewed stated that they care and monitor the residents closely. S3-S4 stated that at approximately 2am on the evening of 10/27/2024, they had just finished doing their rounds, which they do every 2 hours or less. S3 decided to take a break while S4 remained on the floor. Suddenly, S3-S4 heard someone screaming for help and they immediately rushed to the room to respond. Upon entering the room, they found R1 standing up with a bleeding wound. S3 called 911 right away and paramedics came, administered aid and transported R1 to the nearest hospital. Shortly after, the police came to investigate and no arrests were made. R1 does not have a one-on-one caregiver and had wandered into R2-R3's room which startled them. In a state of confusion and self defense, R2 started hitting R1 with a cane and R3 was frozen with fear and unable to move. 4 out of the 7 residents interviewed indicated they were not aware of this incident. Residents interviewed indicated that they feel there is sufficient staff to provide adequate supervision and monitoring to meet their needs. Residents interviewed indicated they feel safe and comfortable at this facility. Therefore there was insufficient evidence to corroborate with the allegation.

Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the 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 and a copy of this report was provided to the Executive Director, Pamela Ogot.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC9099 (FAS) - (06/04)

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