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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602134
Report Date: 10/26/2022
Date Signed: 11/02/2022 09:11:52 AM


Document Has Been Signed on 11/02/2022 09:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:GLEN PARK AT LONG BEACHFACILITY NUMBER:
198602134
ADMINISTRATOR:CAMILLE CRENSHAWFACILITY TYPE:
740
ADDRESS:1046 E 4TH STTELEPHONE:
(562) 432-7468
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY:208CENSUS: 68DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Camille CrenshawTIME COMPLETED:
03:30 PM
NARRATIVE
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On October 26, 2022, Licensing Program Analyst (LPA) Wendy Gibbs and Licensing Program Manager (LPM) Janae Hammond, conducted an unannounced Annual inspection, to ensure infection control measures. LPA and LPM met with Camille Crenshaw, Executive Administrator and explained the purpose of the visit. Facility currently has 68 clients.

The structure is two story building which consist of the following:

The first floor consists of resident rooms, storage rooms, laundry room, living room, art room, visitor restrooms, kitchen, dining room.

The second floor consist of an activity room, resident rooms, and storage rooms.

Bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably.

Bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, a non-skid mat was in place and some residents had chairs as well. Temperature in the bathrooms measured 109.8-110.1 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Kitchen Food supply was checked. Refrigerator was stocked with perishables. Freezer was stocked with frozen meats, vegetables, and fruits. Pantry had ample food supply stocked. Appliances were all in working order.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 10/26/2022
NARRATIVE
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Common areas were clean and for the most part clear of hazards; doorways were free of obstructions.

Linens & Hygiene Supplies: In the storage closet there were an ample supply of pillowcases, mattress pads, fitted sheet, blankets, bedspreads, hand towels, bath towels and wash cloths were observed.

The outdoor perimeter of the building consists of an outdoor two (2) shaded area, outdoor garden, and a designated smoking area. There were three (3) storage sheds by the garden.

Emergency Phone Numbers, Exit Plan & Menu: The telephone land line is operational. Emergency Disaster Plan and "See something, Say something, Let Us Know" posted. Multiple fully charged fire extinguisher were observed on both floors. The facility conducted a fire inspection on August 31,2022. The facility had a fire drill in August 2022.


Clients & Staff Files: Records of staff and clients were reviewed. Records are stored in front staff office.



Medications, First-Aid Kit & Book: Medication is stored in locked medication room. Reviewed MARs for residents. First aid kit was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. They did not have the first aid manual. First aid and medications are available for staff use but inaccessible to clients.

LPA reviewed the Surety Bond and Liability Insurance.

LPA observed staff wearing masks, Visitor Log /Symptom screening Log, Designated isolation room, required Covid-19 Postings, 30 day supply of PPE and other required documents, including phone numbers are posting as mandated by the DPH and CCLD.

LPA informed Administrator that facility fees are overdue.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 10/26/2022
NARRATIVE
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Deficiencies to be cited LPA observed: In room 220 fan cover was missing in the bathroom. In activity room there was an accessible paper cutter. In room 140 resident uses oxygen and there is no sign posted outside of the room. In the garden there was a shovel and pick ax accessible to residents and two (2) storage sheds were unlocked. Storage shed 1 (one) contained hazardous chemicals and storage shed 2 (two) contained gardening tools.

Deficiencies cited under California Code of Regulations Title 22 Division 6, Chapter 8.

Exit interview conducted with Camile Crenshaw and provided with Appeals Rights.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/02/2022 09:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in room 220 the fan in the bathroom did not have a cover over it, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2022
Plan of Correction
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Administrator will ensure the fan will be covered and in good working condition by the plan of corrections date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 11/02/2022 09:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.(1)Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the activity room there was a paper cutter accesibe to residents and in the garden area there was a shovel and pick axe out and storage sheds 1 and 2 were unlocked whose contents contained chemicals and gardening tools which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/27/2022
Plan of Correction
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During the visit the Administrator put the paper cutter, shovel, pick axe in storage areas that are inaccessible to residents. The Administrator also ensured all storge spaces were locked. Cleared at the time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7