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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802560
Report Date: 05/19/2022
Date Signed: 02/03/2023 11:00:37 AM


Document Has Been Signed on 02/03/2023 11:00 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 MONROVIAFACILITY NUMBER:
197802560
ADMINISTRATOR:ACHARYA, NIRJARAFACILITY TYPE:
740
ADDRESS:110 N MOUNTAIN AVETELEPHONE:
(626) 357-6818
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:49CENSUS: 34DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator / Pamela OgotTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Administrator / Pamela Ogot who assisted with the visit. The facility is licensed to serve for a capacity of 49 residents (45 Non-Ambulatory and 4 Bedridden residents only) ages 60 and above. Bedridden residents are to be on the first floor only in rooms with patio door exits. The facility has an approved Hospice Waiver on file for eight (8) Residents. Glen Park at Monrovia has an approved Dementia Care Plan in their plan of operation and accepts residents with dementia. There is no separate memory care unit inside the facility.

During today's visit, LPA used the infection control domain while conducting the Required - 1 Year inspection.
LPA toured the physical plant areas (outside only) to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. The outdoor area was enclosed and no large bodies of water were observed. There are no security bars or weapons on the premises. A shaded area with chairs is provided in the patio area. The trash cans have covered lids.

Due to time constraints, LPA had to terminate visit and will return on a later date to complete the Required - 1 Year inspection by touring the physical plant areas (random selection of resident rooms), checking the facility food supply and reviewing medications/medication records.

No deficiencies were observed during today's visit.
An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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