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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602134
Report Date: 07/09/2021
Date Signed: 07/09/2021 03:25:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 BEACHFACILITY NUMBER:
198602134
ADMINISTRATOR:PINK, MARINA EFACILITY TYPE:
740
ADDRESS:1046 E 4TH STTELEPHONE:
(562) 432-7468
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY:208CENSUS: DATE:
07/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Melissa FloresTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Jade Jordan and Ana Soto conducted an unannounced Annual inspection, to ensure infection control measures, to the above facility. LPAs met with Melissa Flores, Executive Director and the purpose of the visit was discussed. Facility is licensed to serve four (4) ambulatory residents, 174 Non-ambulatory residents and 30 bedridden residents. The facility also has an approved hospice waiver to retain 30 residents.

LPA's toured the physical plant, checked food service, reviewed staff records and reviewed resident files for medical status. The facility conducted a fire inspection in 06/21. The facility is two story building which consist of the following: the first floor consists of resident rooms, , storage rooms, living room, visitor restrooms, kitchen, dining room. The outdoor perimeter of the building consists of an outdoor shaded area, outdoor garden and a designated smoking area. 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. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. LPAs observed an exposed pipe through a cracked wall in linen closet in the first floor from the top of the ceiling to the floor. There was also exposed wires from a ceiling panel..

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.

Technical advisory were given for cosmetic repairs in the residents rooms, and one deficiency cited.

Under Title 22, Division 6 Chapter 8

Exit interview conducted a copy of this report was provided and Appeal rights.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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87303 (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 was not met as evidenced by: LPAs observed Exposed Piping through a cracked wall from ceiling to floor on first floor, and wires hanging from ceiling. This poses a potential health and safety risk to residents in care.
POC Due Date: 07/23/2021
Plan of Correction
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Administrator will submit to LPA a photo of fixed wall by POC due 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: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2021
LIC809 (FAS) - (06/04)
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