198602134-6-9-2022-11-AS-MVAO-CFMTE4-20220622143918

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 05/27/2022
Date Signed: 06/09/2022 10:04:43 AM

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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2022 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20220405101505

FACILITY NAME:	GLEN PARK AT LONG BEACH		FACILITY NUMBER:	198602134
ADMINISTRATOR:	MELISSA FLORES		FACILITY TYPE:	740
ADDRESS:	1046 E 4TH ST		TELEPHONE:	(562) 432-7468
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY:	208	CENSUS: 71	DATE:	05/27/2022
		UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Melissa Flores		TIME COMPLETED:	01:29 PM

ALLEGATION(S):

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Resident sustained a fall resulting in injuries.

INVESTIGATION FINDINGS:

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On 05/27/22 Licensing Program Analyst (LPA) Jade Jordan conducted a subsequent visit; continuing the investigation of allegation(s) above. LPA was met by Facility Director, and the purpose of visit was explained.
Investigation Consisted of: Physical Tour, Interviews With Reporting Party, Administrator, Resident 1 (R1), Roommate of Resident1, Record Review of R1’s Facility Medical History, Medical Records, and Incident Reports.
Regarding Allegation: Resident sustained a fall resulting in injuries.
Investigation Revealed that on 04/05/22, R1 had an Unwitnessed Fall at the facility in their room.
Facility Administrator was notified by R1, of the fall and was sent to Norwalk Community Hospital, same day. R1 sustained injury; of right arm abrasion, low back pain, hematoma on left face lateral to left eye. CT scan showed “Mildly displaced fracture of lumbar vertebra”. Reporting Party (RP) stated due to be a Mandated Reporter, they had to make a report based on severity of injury, and that they were unable to get enough information due to confusion from R1. Rp stated that “R1 did not have a history of being seen in the hospital for falls.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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 11-AS-20220405101505

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
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN PARK AT LONG BEACH	FACILITY NUMBER: 198602134
	VISIT DATE: 05/27/2022

NARRATIVE

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Record Review, and Interviews with Administrator revealed that R1 did not have a history of falls and is ambulatory, R1 did not have a fall plan. Interviews were conducted with R1’s Roommate. They stated that “they had only moved in with R1 for about a month but had never witnessed them fall.” Interviews with R1 stated that no one saw the fall, hadn’t fallen before, and did not feel neglected by the facility, R1 stated they did not remember how they fell.
Based on Interviews Conducted, and Record Review the Department finds that this was an isolated incident,

Therefore :
“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, A copy of this report provided. No citations issued

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC9099 (FAS) - (06/04)

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