197608505-4-5-2025-31-AS-NMAN-DJFSBN-20250710134413

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608505
Report Date: 04/05/2025
Date Signed: 04/05/2025 05:12:05 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/25/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240425103743

FACILITY NAME:	GLEN PARK AT GLENDALE - BOYNTON ST		FACILITY NUMBER:	197608505
ADMINISTRATOR:	PINK, JR, TILLMAN		FACILITY TYPE:	740
ADDRESS:	1250 BOYNTON ST		TELEPHONE:	(818) 246-9000
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	98	CENSUS: 62	DATE:	04/05/2025
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Susan Park		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Facility staff did not administer resident's medication as prescribed.
Facility staff did not provide adequate food service to resident in care.
Facility is operating without a certified administrator.
Staff did not ensure that residents are provided activities while in care.
Facility staff did not prevent resident from engaging in a physical altercation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above noted allegations. LPA met with Susan Park and explained the reason for the visit.

--- Facility staff did not administer resident's medication as prescribed.

It was reported that facility staff did not administer Resident #1 (R1's) medication as prescribed. To investigate the allegation, on 05/01/2024, LPA Abeye Duguma conducted a physical plant tour at around 10:30 AM, requested pertinent documents at 11:00 AM and interviewed one (01) staff from 12:15 PM to 12:35 PM., On 10/02/2024, between 11:45am and 1:00pm, LPA Valenzuela conducted an interview with staff and reviewed facility records between 1:00pm and 2:00pm. To further investigate the allegation, on 04/05/2025, LPA Duguma interviewed six (06) residents and two (02) additional staff from 1:30p.m. – 3:30p.m.
(CONT on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 31-AS-20240425103743

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST	FACILITY NUMBER: 197608505
	VISIT DATE: 04/05/2025

NARRATIVE

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A review of the Medication Administration Record revealed that R1 does receive their medication as prescribed by a physician. During interviews with staff and residents, all stated medications are given as prescribed. LPA Duguma was unable to interview R1 due to current health condition.

Based on interviews and records review there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time.

--- Facility staff did not provide adequate food service to resident in care.

It was alleged that facility staff did not provide adequate food service to a resident in care. It was reported that facility does not provide snacks to R1, in between meals. To investigate the allegation, on 05/01/2024, LPA Abeye Duguma conducted a physical plant tour at around 10:30 AM, requested pertinent documents at 11:00 AM and interviewed one (01) staff from 12:15 PM to 12:35 PM., On 10/02/2024, between 11:45am and 1:00pm, LPA Valenzuela conducted an interview with staff and reviewed facility records between 1:00pm and 2:00pm. To further investigate the allegation, on 04/05/2025, LPA Duguma interviewed six (06) residents and two (02) additional staff from 1:30p.m. – 3:30p.m. During the physical plant tour, LPA Valenzuela observed staff pushing a cart and offering snacks to residents. A review of the facility’s menu shows that residents are served well-balanced meals with desserts and snacks available. During interviews with residents and staff, all stated snacks are available upon request and that food service is adequate.

Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time.

--- Facility is operating without a certified administrator.

It was alleged that facility is operating without a certified administrator. To investigate the allegation, on 05/01/2024, LPA Abeye Duguma requested pertinent documents at 11:00 AM and interviewed one (01) staff from 12:15 PM to 12:35 PM., On 10/02/2024, between 11:45am and 1:00pm, LPA Valenzuela conducted an interview with staff and reviewed facility records between 1:00pm and 2:00pm. To further investigate the allegation, on 04/05/2025, LPA requested for a copy of the Administrator’s certificate.
(CONT on LIC9099-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20240425103743

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST	FACILITY NUMBER: 197608505
	VISIT DATE: 04/05/2025

NARRATIVE

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During the initial visit, LPA was greeted by then Administrator Rafael Silva who was able to produce his Administrator’s Certificate. A review of the facility’s records confirms that facility had a certified Administrator during the time in question. During interviews with staff, all staff stated facility has always had a certified administrator but acknowledged that there have been changes in staffing. This year the facility has had four different administrators.

Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time.

--- Staff did not ensure that residents are provided activities while in care.

It was alleged that staff did not ensure that residents are provided activities while in care. To investigate the allegation, on 05/01/2024, LPA Abeye Duguma conducted a physical plant tour at around 10:30 AM, requested pertinent documents at 11:00 AM and interviewed one (01) staff from 12:15 PM to 12:35 PM., On 10/02/2024, between 11:45am and 1:00pm, LPA Valenzuela conducted an interview with staff and reviewed facility records between 1:00pm and 2:00pm. To further investigate the allegation, on 04/05/2025, LPA Duguma interviewed six (06) residents and two (02) additional staff from 1:30p.m. – 3:30p.m. During the physical plant tour, LPA Valenzuela observed the activities calendar for month inside the arts and crafts room. During interviews with staff and residents, all stated facility has always had activities available for residents to participate in.

Based on interviews and observation, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time.

---Facility staff did not prevent resident from engaging in a physical altercation.

It was alleged that staff did not prevent Resident #2 (R2) from engaging in a physical altercation with R1. R2 pushed hard R1, causing them to fall and hit their head. To investigate the allegation, on 05/01/2024, LPA Abeye Duguma interviewed one (01) staff from 12:15 PM to 12:35 PM. On 10/02/2024, between 11:45am and 1:00pm, LPA Valenzuela conducted an interview with staff.
(CONT. on LIC9099-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20240425103743

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT GLENDALE - BOYNTON ST	FACILITY NUMBER: 197608505
	VISIT DATE: 04/05/2025

NARRATIVE

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To further investigate the allegation, on 04/05/2025, LPA Duguma two (02) additional staff from 1:30p.m. – 3:30p.m. LPA was unable to interview R1 due to current health condition. During interviews with staff, staff stated they immediately had R1 accessed and transported to the hospital for further evaluation. Staff also notified R1's responsible party of the incident. R2 was placed on a 5150 and assured everyone that they would not be returning to the community, due to being a danger to others. Staff told LPA that R2 had been placed on 5150 several times and would return to the community after 72 hours. After this incident, facility refused to accept back R2, due to a series of violent incidents. LPA Valenzuela reviewed incident reports and confirmed what staff had told LPA.

Based on interviews and records review, there is not sufficient information to support the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time.

No health and safety hazards noted at the time of this visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2025

LIC9099 (FAS) - (06/04)

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