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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608505
Report Date: 03/20/2025
Date Signed: 03/20/2025 01:28:15 PM

Document Has Been Signed on 03/20/2025 01:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GLEN PARK AT GLENDALE - BOYNTON STFACILITY NUMBER:
197608505
ADMINISTRATOR/
DIRECTOR:		SUSAN PARKFACILITY TYPE:
740
ADDRESS:1250 BOYNTON STTELEPHONE:
(818) 246-9000
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY: 98CENSUS: 60DATE:
03/20/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Susan ParkTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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At 11:00 a.m. on 03/20/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later the administrator and disclosed the reason for the visit.

Today’s case management visit was conducted after review of the complaint #31-AS-20241023131909 revealed the facility did not apply for an exception for a resident with a worsening prohibited health condition.

To investigate complaint #31-AS-20241023131909, LPA conducted an initial visit on 10/29/24 and interviewed staff and residents between 10:30 a.m. and 12:00 p.m., toured the facility inside and out at 10:45 a.m., and conducted a record review of pertinent records, including but not limited to staff and client rosters at 2:15 p.m. LPA conducted a subsequent visit on 11/06/24 and toured the facility at 1:30 p.m. and conducted a record review of pertinent records, including but not limited to wound care notes at 2:00 p.m. Today, LPA conducted a record review at 10:00 a.m. of additional wound care notes and hospice records of Resident #1 (R1) and toured the facility at 11:15 a.m.

Interview with the administrator at 10:35 a.m. on 10/29/24 revealed no residents currently have prohibited health conditions. There is one (01) resident, R1, who has a Stage 1 pressure injury, which is a restricted but allowable condition in this facility. Record review today of R3’s hospice records and wound care notes from June 2024 to September 2024 revealed that R3 enrolled into hospice services for “other frontotemporal degeneration”. R3’s wound care notes showed they were visited by hospice nurses about twice a week and by wound care specialists about once a week between July 2024 and September 2024. R3 was diagnosed with a Stage 3 sacrococcygeal pressure injury on 06/26/24 and a stage 3 pressure injury on their left heel on 07/03/24. R3’s pressure injury on their heel healed over time and was fully healed by 09/11/24.

R3’s sacrococcygeal pressure injury was smaller in size each week except from 08/07/24 to 08/14/24 when the wound increased from 1.9 centimeters (cm) long x .6 cm wide x .1 cm deep to 3.5 cm long x 1.1 cm wide x .5 cm deep. The wound had grown in size and was not healing during that period of time.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST
FACILITY NUMBER: 197608505
VISIT DATE: 03/20/2025
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A file review at 11:30 a.m. today of an incident report submitted the facility revealed that on 09/17/24, R3 was hospitalized due to needing a higher level of care from their Stage 3 pressure injury which measured approximately .75 inches long (about 1.9cm). Interview with the administrator today at 11:50 a.m. revealed R3’s hospice services expired that day. Therefore, R3 was eventually hospitalized with the prohibited health condition.

Based on interviews and record reviews, when wound care specialists measured R3’s sacrococcygeal pressure injury on 08/14/24 to be larger than the previous week, the facility should have either sent R1 to a facility which could provide a higher level of care or applied for an exception to retain R1 at the facility and continue all services to support R1. The facility did not hospitalize R3 or apply for an exception, and therefore a deficiency is issued on the corresponding LIC809-D page.

Due to disagreeing with today's findings, the licensee and administrator declined to sign this document.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2025 01:28 PM - It Cannot Be Edited


Created By: Nicholas Reed On 03/20/2025 at 12:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST
FACILITY NUMBER: 197608505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/31/2025
Section Cited
HSC
1569.73(b)

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§1569.73 Terminally ill residents... (b) At any time that… the facility... determines that the resident's condition has changed ... the facility may initiate procedures for a transfer.
This requirement was not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the section cited above by retaining Resident #1 (R1) with a worsening prohibited health condition and not applying for an exception which posed a potential Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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