197802560-8-3-2022-28-AS-RORN-CHSSUV-20220830141144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 08/03/2022
Date Signed: 08/03/2022 04:06:59 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
01/04/2022 and conducted by Evaluator Elizabeth Ceniceros

COMPLAINT CONTROL NUMBER: 28-AS-20220104084811

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:	11:30 AM
MET WITH:	Administrator, Pamela Ogot, MBA		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff locked resident in their room.

Staff did not follow resident's care plan.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made the unannounced visit to the facility and was greeted by Administrator (A1: Pamela Ogot). LPA/RA had spoke to A1 prior to entering the facility to conduct a risk assessment. A1 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms.

LPA/RA Ceniceros explained to A1 the purpose of today's visit is to deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day visit was conducted by LPA Elizabeth Irra on 01/10/22. During this visit, LPA obtained a copy of the Staff Roster, Resident Roster, and reviewed Resident #1's file and obtained relevant documentation. LPA/RA toured the faciity and visited Resident #1 and observed Staff #

Regarding Allegation #1: this investigation revealed based on interviews conducted (between 12:30 p.m. to 2:45 p.m.) of facility staff and residents, the majority had not witnessed a resident's bedroom door tied to a hand rail with a plastic bag - while a resident was in his/her bedroom. LPA/RA could not conduct an

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-20220104084811

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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interview with Resident #1 due to its non-verbal communication. LPA/RA Ceniceros toured the facility to observe Resident #1's bedroom door next to the hand rail, it appears that all of the resident's bedroom door is adjacent to a hand rail (photograph). The photograph provided did not document a room number on the door; therefore, it could not be determined if Resident #1's bedroom door had been tied to the hand rail on or about 12/30/21. Resident #1 receives 1:1 care; therefore, the resident has a 24/7 caregiver at all times.

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 locked resident in their room is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on Resident #1's records review and interviews conducted (between 12:30 p.m. to 2:45 p.m.) of Administrator and Staff #2 - Staff #5, Resident #1 receives 1:1 care 24 hours a day/7 days a week based on the December/January 2021 Calendar Year and Weekly One-on-One Schedule (dated 12/26/21 to 01/01/22), Resident #1 had 1:1 staff assigned to its care. In addition, the facility is contracted with Angel Care Staffing Agency should the facility experience a staffing shortage. On the date in question (12/30/21), Resident #2 stated that it didn't mind Resident #1 coming into its room to get candy or cookies or a soda because that's what it's there for to share with the 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 NEGLECT/LACK OF SUPERVISION: Staff did not follow resident's care plan is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Staff #2 (S2: Martha Uribe Rosas, Facility Manager); as Administrator (Pamela Ogot, MBA) was unavailable.

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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