<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 04/18/2024
Date Signed: 02/05/2025 02:54:33 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2024 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20240412162721
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: 93DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:SHENICK JACKSONTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medications.
Staff did not administer medication as prescribed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/05/2025, the department conducted a subsequent complaint visit to amend the original LIC9099 and LIC9099Cs dated 04/18/2024, but this does not change the findings of this complaint. The department met with Office Manager Shenick Jackson and explained the purpose of the visit was to amend the original LIC9099 and LIC9099Cs dated 04/18/2024. The original LIC9099 and LIC9099Cs dated 04/18/2024 are being amended. The revised LIC9099 and LIC9099Cs dated 08/07/2024. On 04/18/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a complaint visit to deliver findings regarding the above allegations. LPA Richard met with Receptionist/MedTech Claudia Magana and later was joined with assistant Administrator Tonantzin Marines and Executive Director Michael Mendoza and explained the reason for the visit. The investigation consisted of the following: On 04/18/2024, LPA Richard and Receptionist/MedTech Martinez toured the facility inside and out. LPA Richard reviewed and requested, staff and resident's roster. Preplacement Appraisal Information, Individual Services Plan (ISP), Physician's Report for Residential Care for the Elderly (RCFE). Admission Agreement, Transfer Discharged Report. New Telephoned Prescription. Basic Medication Shadow training. LPA interviewed seven (7), residents (R1-R7), and three (3) staff (S1-S3). LVN, and Med Tech. LPA Interviewed the Nurse Practitioner (NP) Vartan Bekerian.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
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 4
Control Number 11-AS-20240412162721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 04/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Staff mismanaged the resident's medication.

The Investigation revealed the following:

Regarding the allegation, “Staff mismanaged the resident’s medication”, it is being alleged Resident #1’s (R1) medication A (Haldol) was not discontinued. Medication Administration Record (MAR) revealed medication A was still being administered since R1 was admitted on 03/26/24. Interview with the Med Tech indicated that: on 03/26/2024, R1 was admitted to the facility from a skilled nursing facility with a medication list that included medication A; on 04/12/2024, R1’s Power of Attorney (POA) called the facility requesting medication A to be discontinued, but the facility refused since there wasn’t a doctor’s order; on 04/15/2024, the facility received a new prescription order from the R1’s doctor and pharmacy about discontinuing medication A. The department reviewed the MAR dated 03/26/2024 to 04/18/2024 and observed medication A was discontinued on 04/15/25. The department interviewed three staff #S members (S1-S3) and 3 out of 3 stated that they could not stop giving medications to residents unless it’s from a doctor’s order. The department interviewed seven residents #R (R1-R7) 6 out of 7 stated that they do not have any problem with the facility managing their medications.

Based on interviews, and records reviewed the department did not find sufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

(Evaluation Report Continues LIC 9099-C)

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240412162721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 04/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: #2 The staff did not administer medication as prescribed.

Regarding the allegation: “The staff did not administer medication as prescribed,” it is alleged that the staff continued to give medication B (Zoloft) in the morning instead of the evening. Medication Administration Record (MAR) revealed that R1’s medication B is to be administered in the morning and staff distributed it in the morning. The department interviewed the Med Tech (MT) about the allegation, and MT denied the allegation and stated that (R1) was admitted to the facility on 03/26/2024 and R1’s medication B was administered per the physician’s directions on time, and the right doses. On 04/18/2024, the department reviewed seven residents' medication administration records (MARs) and 7 out of 7 records show that medication was given to the residents in the correct dosage and at the proper times. The department Interviewed the Licensed Vocational Nurse, (LVN) they denied the allegation and stated that we cannot stop giving or changing the time of administering (R1) medication because a family member or Power of Attorney (POA) wants us to. Based on interviews and records reviewed the department did not find sufficient evidence to support the allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated

(Evaluation Report Continues LIC 9099-C)

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20240412162721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 04/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
No deficiencies cited. Exit interview conducted and a copy of this report was provided to Office Manager Shenick Jackson.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4