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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 04/25/2022
Date Signed: 04/25/2022 04:41:58 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/30/2021 and conducted by Evaluator Jey Cardenas
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210930152624
FACILITY NAME:GLEN PARK AT LONG BEACHFACILITY NUMBER:
198602134
ADMINISTRATOR:MELISSA FLORESFACILITY TYPE:
740
ADDRESS:1046 E 4TH STTELEPHONE:
(562) 432-7468
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY:208CENSUS: 70DATE:
04/25/2022
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Melissa FloresTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident aquired scabies while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jey Cardenas conducted a subsequent complaint visit to the above facility to deliver findings into the above allegation. Upon arrival at the facility LPA meet with administrator Melissa Flores and explained the reason for today’s visit.

The investigation consisted of the following: Initial visit was conducted on 10/06/21 LPA interviewed administrator, Melissa Flores, Staff#1-3 (S1-S3) and obtained Resident#1 (R1) Physician report, appraisal, and functioning capabilities. On 3/28/22 LPA conducted subsequent visit and interviewed seven (7) residents and one (1) staff.

Regarding allegation: Resident acquired scabies while in care. On 10/06/2021 LPA Cardenas interviewed administrator Melissa Flores who indicates that R1 had not been confirmed to have scabies. R1 was on hospice and nurses were using scabies medication on R1 but there was never confirmation that resident indeed have scabies. Flores states that resident has not had scabies in the past.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
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 5
Control Number 11-AS-20210930152624
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 04/25/2022
NARRATIVE
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On 10/07/2021 LPA Cardenas spoke with Hospice registered nurse, John Chen who indicates that R1 has a skin rash, it has not been confirmed that it is scabies. He states that there was no burrowing. Per the hospice instructions Dr. prescribed permethrin cream as a preventative measure, and he is only follow hospice protocol. On 4/22/22 LPA Cardenas spoke with Norwalk Community Hospital who indicates that resident was brought in with scabies treatment, however there is no confirmation that resident had scabies at time of admission.

“Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.” Exit interview conducted and a copy of this report was provided to Melissa Flores.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/30/2021 and conducted by Evaluator Jey Cardenas
COMPLAINT CONTROL NUMBER: 11-AS-20210930152624

FACILITY NAME:GLEN PARK AT LONG BEACHFACILITY NUMBER:
198602134
ADMINISTRATOR:MELISSA FLORESFACILITY TYPE:
740
ADDRESS:1046 E 4TH STTELEPHONE:
(562) 432-7468
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY:208CENSUS: 70DATE:
04/25/2022
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Melissa FloresTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident received an injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jey Cardenas conducted a subsequent complaint visit to the above facility to deliver findings into the above allegation. Upon arrival at the facility LPA meet with administrator Melissa Flores and explained the reason for today’s visit.

The investigation consisted of the following: Initial visit was conducted on 10/06/21 LPA interviewed administrator, Melissa Flores, Staff#1-3 (S1-S3) and obtained Resident#1 (R1) Physician report, appraisal, and functioning capabilities. On 3/28/22 LPA conducted subsequent visit and interviewed seven (7) residents and one (1) staff.

Regarding allegation: Resident received an injury while in care- On 10/06/2021 LPA interview reporting party, R1 has left hip pain, left hip fracture and is receiving physical therapy. R1 is confused, required direction, can ambulate with assistance, and is a high fall risk. On 10/06/2021 LPA Cardenas interviewed administrator, Melissa Flores who indicates that R1 is on hospice, has dementia
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20210930152624
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 04/25/2022
NARRATIVE
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(cont pg 2)
is ambulatory but has difficulty walking upstairs, R1 can get out of bed unassisted and is not a fall risk, resident has had two falls since being at facility. Per interview with S1, staff stated that she was getting residents ready to take them to the dinning room. S1 fixed R1s hair and left resident sitting on the bed; staff walked out of the room for five minutes and when she returned, she saw R1 on the floor by the door. R1 couldn’t communicate what happened.
LPA Cardenas reviewed medical records from Norwalk Community Hospital, On 09/29/2021 R1 arrived to Norwalk Community hospital with left hip pain due to unwitnessed fall at the facility. X-ray hip and pelvis 2 views showed left femoral neck fracture, there are also nondisplaced fractures of the left superior and interior pubic rami. On 12/08/2020 R1 was admitted to Emergency room Chief complaint: Left arm pain, “patient apparently fell from bed at the facility 10 days ago.” On arrival the left arm is swollen. X-ray on the left humerus shows a fracture dislocation of the proximal humerus.

LPA Cardenas reviewed R1’s facility records: Per Physician report dated 10/27/20 R1 primary diagnosis is Dementia, resident is confused, disoriented and non-ambulatory. Per most recent Appraisal on file is dated 4/18/19: R1 is Active but has difficulty climbing/ descending stairs, uses walker, Needs no special observation. Per Unusual incident report (UIR) on 9/28/21 S1 found R1 inside the resident’s bedroom on the floor. R1 was admitted to the hospital with a confirmed left hip fracture. Per UIR on 08/14/21 R1 fell out of chair while eating breakfast. R1 didn’t not have re-appraisal, it was not completed after residents’ hospitalization's for fall. Initial physicians report was completed 04/09/2019 and second physician report was completed 10/27/2020, Dementia residents should have a physician report completed every year.

LPA Cardenas reviewed Steward Hospice Plan of care, R1 is recertified due to declining condition, R1 is diagnosed with Senile Degeneration of Brain. Continues to have a slow and steady decline in condition. R1 is very confused and is a fall risk (ongoing problem.) POA is notified regarding unusual gait. Recommended use of wheelchair during mealtime.
Based on LPA’s interviews, and record review(s), the preponderance of evidence standard has been met, therefore the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D. Exit interview conducted and a copy of this report and appeal rights provided to Melissa Flores. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1)
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210930152624
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2022
Section Cited
HSC
1569.49(c)(1)
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Any violation that the department determines resulted in the injury or illness of a resident. This requirement not met as evidenced by: On 09/28/2021 R1 had a fall and sustanined left femoral neck fracture. This poses an immediate health and safety risk to residents.
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Submit written plan on how facility plans to ensure residents are provided with the services required, needs and serivces plan will be completed and updated as needed. (immediate civil penalty issued on today 4/25/2022.)
Type B
04/29/2022
Section Cited
CCR
87463(a)
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Reappraisals The pre-admission appraisal shall be updated, in writing... This requirement not met as evidenced by: LPA reviewed R1s file and found facility failed to reappraise resident after inital fall.
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Facility will ensure that resident is reappriased to ensure facility can meet residents needs and provides adequate care and supervision.
Type B
04/29/2022
Section Cited
CCR
87705(c)(5)
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Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs...This requirement not met as evidenced by:
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Facility will ensure all dementia residents have updated mediacal assessement annually. Submit self certification indicating this requirment will be met.
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Durin record review LPA observed inital Physician report dated 4/9/19, second report was dated 10/27/2020 which doesnt comply with required annual medical assessment.
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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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5