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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608506
Report Date: 02/14/2025
Date Signed: 02/14/2025 03:14:47 PM

Document Has Been Signed on 02/14/2025 03:14 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GLEN PARK AT GLENDALE - MARIPOSA STFACILITY NUMBER:
197608506
ADMINISTRATOR/
DIRECTOR:		SUSAN PARKFACILITY TYPE:
740
ADDRESS:1220 S MARIPOSA STTELEPHONE:
(818) 242-9000
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY: 120CENSUS: 86DATE:
02/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Susan Park / Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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In conjunction with control number 31-AS-20250207131924 complaint visit, Licensing Program Analyst (LPA) Evelin Rios did an unannounced CASE MANAGEMENT - Deficiencies visit. A case management report is being issued today in conjunction to the complaint visit report for observed deficiencies not related to complaint. LPA met with Susan Park the Executive Director.

During the course of complaint investigation, interview with Executive Director and review of Personnel Report (LIC500) revealed staff #1 (S1) is not on the report. According to ED, S1 was hired as a caregiver from a temporary agency. According to interviews S1 has worked for the facility for over a year in the capacity as receptionist and caregiver. Based on staff interviews, at least on one occasion S1 has been alone to provide care and supervision to one (1) resident. Review of Guardian Background Check System and Licensing information System (LIS) S1 is background cleared but not associated to the facility.

Per the California Code of Regulations (CCR), the following deficiencies were observed and cited (refer to LIC 809-D) and a Civil Penalty assessed (refer to .

Exit Interview Conducted / Appeal Rights Discussed / A Copy of Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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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Document Has Been Signed on 02/14/2025 03:14 PM - It Cannot Be Edited


Created By: Evelin Rios On 02/14/2025 at 02:36 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 - MARIPOSA ST
FACILITY NUMBER: 197608506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2025
Section Cited
CCR
87355(e)(2)

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87355(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
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Administrator will not allow staff to work at the facility unless proper transfer clearance is submitted to CCLD.
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Based on record review and interviews, licensee failed to have staff #1 (S1) associated to the facility or transfer of a criminal record clearance which is an immediate health and safety risk to residents 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:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
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