197802560-4-5-2023-28-AS-MVAO-CTMSTE-20230711140926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802560
Report Date: 04/05/2023
Date Signed: 04/05/2023 02:58:46 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
03/27/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230327110541

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: 38	DATE:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Assistant Administrator- Martha Rosas		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not communicate necessary medical information to resident's designee in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted a complaint investigation at the facility regarding the above allegation. LPA met with Assistant Administrator Martha Rosas and explained the reason for the visit.

LPA Calderon requested Resident and Staff Roster, copies of Resident #1 (R1) file: Identification Emergency Information, Physician's Report, and Appraisal/Needs and Service Plan. R1's Special Incident Reports (SIRs) related to allegation stated above and Hospitalization Records. LPA received email confirmation and reporting fax confirmations. LPA interviewed Assistant Administrator Martha Rosas and telephonically called R1 but was unsuccessful and telephonically interviewed San Gabriel/ Pomona Regional Center (SGPC).

Continuation on LIC 90999-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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-20230327110541

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: 04/05/2023

NARRATIVE

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Based on investigation, regarding allegation: Staff did not communicate necessary medical information to resident's designee in a timely manner. LPA Calderon interviewed Assistant Administrator who denied the above allegation stating all responsible parties were notified. LPA interviewed Service Coordinator at SGPC stating incident occurred on 3/20/23 and stated facility reported via SIR on 3/21/23. LPA reviewed email confirmation from facility to SGPC regarding R1, SGPC was notified within 24 hour time frame and follow ups were provided based on SIRs reviewed. LPA reviewed SIR and reviewed facility submitted an SIR to Community Care Licensing in a timely matter, within the 7 day reporting requirement.

Based on LPA's record review and interviews, the investigation revealed: 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 conducted with Assistant Administrator Martha Rosas and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

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