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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602134
Report Date: 10/07/2023
Date Signed: 10/09/2023 08:30:03 AM


Document Has Been Signed on 10/09/2023 08:30 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:GLEN PARK AT LONG BEACHFACILITY NUMBER:
198602134
ADMINISTRATOR:MICHAEL MENDOZAFACILITY TYPE:
740
ADDRESS:1046 E 4TH STTELEPHONE:
(562) 432-7468
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY:208CENSUS: 91DATE:
10/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:ADMINISTRATOR MICHAEL MENDOZATIME COMPLETED:
03:00 PM
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On 10/07/2023 at 8:45AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at Glen Park at Long Beach Facility. LPA Calderon was allowed entry into the facility by Administrator Michael Mendoza. The facility is licensed for 208 residents aged 60 and over. Currently, there are (91) residents residing in the facility 60 years or older.

LPA Calderon explained to Administrator Michael Mendoza, the purpose of the 1-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: six (6) resident service records, six (6) resident medication records, and LPA Calderon interviewed six (6) residents and six (6) staff members for visit. LPA Calderon inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 09/08/2023. The two-story commercial building consists of one hundred (100) resident bedrooms, one hundred (100) resident bathrooms, three (3) common bathrooms, dining room, commercial kitchen, staff room, office area, library, Media room, Garden area, washer and dryer/ storage area, backyard with umbrella with table and chairs. No weapons are stored in the premises. Commercial Kitchen was inspected and observed to be clean and operational. A 2-day supply perishable and 7-day supply of non-perishable foods are present in the facility kitchen. Emergency Water Storage is in found inside locked shed of the facility grounds.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2023
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 10/07/2023
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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms #101, #103, #106, #201, #206, #210: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 113 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 111 degrees Fahrenheit, and Bathroom #3 hot water temperature properly measured at 110 degrees Fahrenheit. Commercial kitchen hot water temperature properly measured at 118 degrees Fahrenheit. Facility sixty (60) Carbon Monoxide and sixty (60) Smoke Detectors hard wired and connected were tested and are working properly. The facility twenty (20) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked medication room. Facility first aid kits (10) is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Six (6) staff files were checked and have the required documents. The facility does handle resident's money/cash resources. Western Surety Bond Company #7170749 for $10,000.00 was valid at time of inspection. All the required documents are posted in the facility in a clearly visible area. LPA Calderon noted the Administrator Michael Mendoza Certification # 6021836740 expiration date of 12/30/2020 was NOT valid at time of visit (ADMINISTRATOR HAS 83 TRAINING HOURS FROM MARCH TO JUNE 2023 AND IS WAITING HIS NEW ADMINISTRATOR CERTIFICATION). Commercial General Liability Policy #LTC-21200055-02 policy period from 12/05/2022 to 12/05/2023 underwritten by Healthcare Professional Long Term Care Insurance company coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Michael Mendoza who will email full copy of insurance contact which shows all coverages to LPA Calderon no later than 10/20/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Calderon reviewed LIC500 and noted all staff associated to facility per LIS. LPA Calderon reviewed the resident roster, LPA Calderon confirmed residents’ interview are on resident roster.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2023
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 10/07/2023
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LPA advised the Administrator Michael Mendoza to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Michael Mendoza.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2023
LIC809 (FAS) - (06/04)
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