197802560-8-3-2022-28-AS-MVAO-CH7T42-20220811142315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 08/03/2022
Date Signed: 08/03/2022 04:05:35 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
09/04/2020 and conducted by Evaluator Elizabeth Ceniceros

COMPLAINT CONTROL NUMBER: 28-AS-20200904173150

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: 37	DATE:	08/03/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Administrator, Pamela Ogot, MBA		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff didn't treat resident with dignity and respect.

Staff member was impaired while on the job.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #2 (S2: Martha Uribe Rosas, Facility Manager); as Administrator was unavailable until 0830 hours. LPA/RA spoke to S2 prior to entering the facility to conduct a risk assessment. S2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms.

LPA/RA explained to A1 the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day virtual visit was conducted by LPA Joe Katrdzhyan on 09/11/20 (via telephone) with Staff #2 (S2: Martha Uribe Rosas) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. During the virtual call with S2, LPA Katrdzyan interviewed Staff #2 (Facility Manager) and requested copies of documents in reference to (former) Resident #1 and former Staff #1 (S1: Jenell H., Residential Care Specialist).

(Cont on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

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-20200904173150

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: 08/03/2022

NARRATIVE

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Regarding Allegation #1: this investigation revealed based on interviews conducted (between 9:00 a.m. to 10:25 a.m.) of facility staff and residents, the majority had not observed facility staff mistreat Resident #1 or address any name calling (racist) towards the resident. It was (also) agreed that facility staff treats all residents with dignity and respect. It was not witnessed by the majority of staff and residents that (former) Administrator Michael Mendoza would discuss politics or make derrogatory statements towards Resident #1 or staff and other residents.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of PERSONAL RIGHTS: Staff didn't treat resident with dignity and respect is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on interviews conducted (between 9:00 a.m. to 10:25 a.m.) of facility staff and residents, the majority had not observed a facility staff member behaving inappropriately while on the job and making derrogatory comments towards Resident #1, staff or other residents. A review of the facility's training records documented that the facility provided facility staff with training on the topic: "Personal Rights of Residents in Residential Care Facilities for the Elderly" on 12/02/2020, 10/18/21, and 06/15/22.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of OTHER: Staff member was impaired while on the job is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Administrator, Pamela Ogot, MBA..

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC9099 (FAS) - (06/04)

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