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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802560
Report Date: 04/04/2024
Date Signed: 04/04/2024 04:49:16 PM

Document Has Been Signed on 04/04/2024 04:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GLEN PARK AT MONROVIAFACILITY NUMBER:
197802560
ADMINISTRATOR/
DIRECTOR:		ACHARYA, NIRJARAFACILITY TYPE:
740
ADDRESS:110 N MOUNTAIN AVETELEPHONE:
(626) 357-6818
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 49CENSUS: 45DATE:
04/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Pamela Ogot - Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management visit to investigate a self reported incident received by CCLD on 3/27/2024 of suspected elder abuse by staff on Resident #1. LPA met with the Executive Director, Pamela Ogot and explained the purpose of the visit.
The report stated that on 3/18/2024 at about 2:50am, Staff #1 (S1) witnessed another staff (S2) hit the lower body part of Resident #1 (R1) with his hand and screamed at the same time because R1 refused to be changed.
During today's visit, LPA interviewed the Executive Director, and obtained copies of the staff/resident rosters,and R1's latest Physician's report. Per the Executive Director, the incident happened on 3/18/2024 at 2:50am. S1 did not report it to her until 3/22/2024 at 5:30pm over the phone. Executive Director conducted an immediate investigation and spoke with S2 the same day who denied the allegation. The following day, the Executive Director spoke with R1 and performed a body check on her, no noticeable injuries found. On 3/23/204, Executive Director reminded S1 to submit an incident report to her, but S1 never did. On 3/24/2024, S1 did not show up for work. S1 reported back to work on 3/26/2024 and submitted a letter of resignation the following day, 3/27/2024. According to the Executive Director, there was no credible evidence found on her investigation to substantiate it.
LPA reviewed R1's Physician's report which showed that R1 is non ambulatory with cognitive impairment and requires assistance with activities of daily living. LPA spoke with R1 in person during the visit, and R1 could not remember the staff nor an incident of being hit on the lower part of the body. LPA observed that R1 was speaking and walking normally. LPA was unable to find anyone to corroborate that the alleged incident or physical and verbal abuse occurred at this time. Based on the information gathered, there is no signs of neglect or lack of supervision found.

No deficiency was issued. An exit interview was held, and a copy of this report was provided to the Executive Director, Pamela Ogot.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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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