197608506-1-15-2025-31-AS-NMAN-DFJUXF-20250408155816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:16:30 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
01/07/2025 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20250107111055

FACILITY NAME:	GLEN PARK AT GLENDALE - MARIPOSA ST		FACILITY NUMBER:	197608506
ADMINISTRATOR:	SUSAN PARK		FACILITY TYPE:	740
ADDRESS:	1220 S MARIPOSA ST		TELEPHONE:	(818) 242-9000
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	120	CENSUS: 89	DATE:	01/15/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Susan Park		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff served expired food to a resident in care.
Staff did not administer medications as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an initial complaint visit to the facility to investigate the above allegations. LPAs met with Executive Director, Susan Park, and explained the reason for the visit.

--- Staff served expired food to a resident in care.

It was alleged that facility served moldy bread. To investigate the allegation, LPA conducted a physical plant tour at around 9:30a.m., interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. to 1:00p.m. During the physical plant tour, LPA did not observe any expired foods or moldy breads. During interviews with residents, Resident #1 (R1) stated they asked for bread the other day and was served moldy bread.
(CONT. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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 31-AS-20250107111055

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 - MARIPOSA ST	FACILITY NUMBER: 197608506
	VISIT DATE: 01/15/2025

NARRATIVE

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R1 added when they asked why, staff replied it is because they asked specifically for sourdough and they only had a few slices. All other residents stated they are not served expired foods or moldy bread. During interviews with staff, all staff stated they do not recall the incident and do not serve expired foods or moldy breads to residents.

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

--- Staff did not administer medications as prescribed.

It was alleged that staff do not administer medications on time. To investigate the allegation, LPA requested documents at around 9:30a.m., interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. to 1:00p.m. A review of Resident #2’s (R2) Medication Administration Records lists all medications, however, there are many empty spaces. When staff were questioned about the blank spaces, they stated it is a system error they have not been able to fix it, and the meds were given on those dates. The records also have several “refused” and “away” indications for medications. During interviews with residents, R1 and R2 stated facility does not give two (02) of the medications to R2 during food as prescribed. R1 and R2 added that one (01) of the MedTechs refused to give R2 medications while they were in R1’s room. During interviews with staff, Staff #2 (S2) stated they give R2 their medications as prescribed but at times R2 either does not wait for the medications to be given or refuses medications entirely. S2 added, R2 is sometimes away without prior notice. All other staff stated, to their knowledge, residents are being given their medications as prescribed.

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

No health and safety hazards were noted during the visit.

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

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC9099 (FAS) - (06/04)

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