197802560-3-19-2026-28-AS-DKOI-DSBVER-20260319162246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802560
Report Date: 03/19/2026
Date Signed: 03/19/2026 04:23:32 PM

Document Has Been Signed on 03/19/2026 04:23 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GLEN PARK AT MONROVIA		FACILITY NUMBER:	197802560
ADMINISTRATOR/ DIRECTOR:	ACHARYA, NIRJARA		FACILITY TYPE:	740
ADDRESS:	110 N MOUNTAIN AVE		TELEPHONE:	(626) 357-6818
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY: 49		CENSUS: 40	DATE:	03/19/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:48 PM
MET WITH:	Pamela Ogot, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	04:35 PM

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit. LPA met with Executive Director Pam Ogot and LPA explained the purpose of the visit. Executive Director helped assist the LPA with the inspection. Facility is licensed for 45 non-ambulatory, maximum of (8) hospice residents and (4) bedridden residents ages 60 and over. Currently, there are (40) residents in the facility who are 60 years and older, of which no residents are bedridden and two (2) are receiving hospice care.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan. Staff are adhering to infection control requirements. Emergency and disaster plan was completed and up to date. Infection control practices and Personal Protective Equipment (PPEs) were maintained.

Operational Requirements: The Infection Control Plan has been added to the Plan. Facility accepts and retains residents with dementia. Approved Dementia Care Plan is in their plan of operation. There is no separate memory care unit inside the facility. Facility is approved for (8) hospice residents. Liability Insurance is in place. Surety bond is in place. Fire drill was last conducted on 02/20/2026. Disaster drill was last conducted on 02/20/2026.

Physical Plant/Environment Safety: LPA along with Executive Director toured the facility. The facility is a 2-story building located in a residential community. The grounds in the facility are well landscaped and have a leveled walkway to the entrance of the building. The facility consists of: First floor: Lobby, Administrative offices,

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN PARK AT MONROVIA	FACILITY NUMBER: 197802560
	VISIT DATE: 03/19/2026

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Physical Plant/Environment Safety [Cont.]: Medication room, Laundry room, (1) Elevator, Large Dining area, Kitchen, Pantry, Activity room/patio, Storage room, Patio by the main entrance, and resident rooms. Second floor: Resident bedrooms, Beauty shop, Activity room and a community shower. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility is equipped with cameras in the common areas. LPA toured random rooms and observed each bedroom to contain the required furniture and linens. Extra linens and towels are in the storage room Each residents' room has their own restroom. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in six (6) random resident rooms (Rooms #1, #7, #9, #207, #211, #215) in the first & second floors and the water temperature readings were from 109.5 degrees F to 113.5 degrees F which were within the required 105 - 120 degrees Fahrenheit. LPA observed call signals in six (6) random resident rooms and were working properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operational and compliant. Two (2) Carbon Monoxide detectors were tested and are operable. LPA observed five (5) fire extinguishers throughout the facility and are fully charged and last inspected on 01/29/2026. Pull Fire alarm system observed and connected to the City of Monrovia Fire Department. Delayed egress devices are in place. No bodies of water were observed at the facility. There are no security bars or weapons on the premises.

Staffing: A total of (34) staff members provide care and supervision to the residents, including the Executive Director. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records-Training: LPA reviewed six (6) staff files which include Job Application, health screening, TB clearance, medication management training, Employee Rights, food handling certificates, and 1st Aid/CPR/AED training. Executive Director's Administrator’s Certificate expires on 09/15/2026.

Resident Rights-Information: Resident personal rights, complaint hotline information and visitors policy posters are posted in the lobby by the main entrance. The facility provides internet service to all residents and have access to the facility phone.

Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted in the hallway. The facility has a Resident Council and council members/residents meet on a monthly basis.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN PARK AT MONROVIA	FACILITY NUMBER: 197802560
	VISIT DATE: 03/19/2026

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Food Service: Sufficient food supply is stored in the kitchen and pantry area consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. Per Executive Director, there are no residents with a modified diet. LPA observed unlabeled food containers in the freezer and refrigerator.

Incident Medical and Dental: Medications are centrally stored and properly labeled in their original containers or bubble packs. First aid kits are maintained in the medication room and in the front office. LPA reviewed five (5) residents medications in the medication room with no issues observed. Medical and dental transportation is provided.

Resident Records/Incident Reports: LPA reviewed five (5) resident files that include Identification and Emergency Information Form, Admission Agreements, Physician's Reports, Pre-Placement Appraisal, TB clearance, Ambulatory Status, Functional Capability Assessment, Physician's Orders, Personal Rights, Appraisal Needs and Services Plan.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Facility provides training on staff's responsibilities during an emergency or disaster.

Residents with Special Health Needs: Per Executive Director, (38) residents are receiving home health services, two (2) residents are under hospice care and no residents are bedridden. Facility admits residents with dementia and staff files reviewed today all have required training documented. LPA observed half bed rails for mobility assistance in some resident beds. Physician orders for bed rails are in file. There are no residents with prohibited health conditions.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during today’s visit. Exit interview was held and a copy of the report was provided to the Executive Director, Pamela Ogot.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

LIC809 (FAS) - (06/04)

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