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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 01/27/2024
Date Signed: 01/27/2024 02:29:30 PM

Substantiated


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
12/22/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20231222170043
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: 96DATE:
01/27/2024
UNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Claudia Magana & Michael MendozaTIME COMPLETED:
01:47 PM
ALLEGATION(S):
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Facility staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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On 01/27/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent visit at this facility to deliver findings for this complaint. LPA was greeted by Receptionist Claudia Magana who contacted the Administrator Michael Mendoza. LPA explained the purpose of the visit and read the findings to Mr. Medoza.

Investigation cosisted of the following: Licensing Program Analyst (LPA) Jose Calderon conducted the initial complaint visit on 12/27/23. LPA Calderon interviewed Administrator Michael Mendoza A1, R1-R10, S1-S2. This interview was conducted on 12/27/2023. On 12/27/2023 LPA Calderon obtained and reviewed copies of the following: Incident report (dated 12/09/2023) and (dated 12/11/2023). Physician report (dated 11/15/2021 and 10/19/2021), Needs and Service (dated 10/25/2023), (11/25/2023) Video (date 12/08/2023).

*This report serves as an amendment to the report created 12/27/23. This report supersedes the complaint investigation findings reflected in the report created 12/27/23.
(Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
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-20231222170043
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: 01/27/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Regarding Allegation #1: Facility staff did not safeguard residents’ personal belongings.

This complaint alleged staff did not safeguard R1’s belongings. LPA Calderon interviewed with A1. A1 stated that A1 spoke to R1's family members and was advised that personal items were missing from R1's room. A1 stated that A1 reviewed the video for 12/08/2023 around 8:30 am. A1 reported that A1 watched R2 use a key to enter the room of R1 three times. A1 stated that the video showed R2 taking a stuffed animal, a small painting, and markers. A1 claimed that A1 searched R2's room and found R1's items. A1 expressed that S1 found R1's wallet with money in the laundry area. A1 stated that R1's family members counted the money, and the money was never stolen. A1 stated that R2 was shown the video and R2 stated that the video was not R2 and it someone else. LPA Calderon interviewed with S1-S2. S2 communicated that S2 picked up R1's dirty clothes when R1 was in the hospital. S1 said that S1 found an unknown amount of money, two silver coins, a credit card, and two rings. S1 stated that S1 gave items to the manager for safekeeping. S2 stated that S2 received an order to change all the resident room locks with a self-locking door to prevent residents wandering to enter unlocked rooms.

LPA Calderon interviewed with R1-R10. LPA Calderon called R1 at the hospital and left two messages. R2 recalled that R2 did not use any key or enter the room of R1. R2 stated that the video showed R2 entering R1’s room with a key and taking items that are not R2. 8 out of 10 residents reported that no one has taken or stolen any items from the resident room and 8 out of 10 state that staff safeguards their personal belongings. LPA Calderon reviewed the video dated 12/08/2023. The video showed R2 using a key to enter R1's room. The video showed R2 taking items from the room. LPA Calderon reviewed the video with R2 who claimed the unknown person is not R2. LPA Calderon toured the facility with S2 and noted new locks for residents’ doors. LPA Calderon reviewed the needs and service plan for R1 and R2 (date 10/25/2023 and 11/15/2023). R1 has no cognitive issues while R2 has health issues. Reviewed incident reports (dated 12/09/2023 and 12/11/2023). Incident reports suggest that R2 did use a key to enter R1's room. The incident report indicated that $91.00 was returned to R1 and was never stolen or taken by R2.

(Evaluation Report continues LIC 9099-C)

*This report serves as an amendment to the report created 12/27/23. This report supersedes the complaint investigation findings reflected in the report created 12/27/23.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20231222170043
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: 01/27/2024
NARRATIVE
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Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation that “Facility staff did not safeguard residents’ personal belongings” is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citations issued (ref LIC9099D).

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the receptionist Claudia Magana.

*This report serves as an amendment to the report created 12/27/23. This report supersedes the complaint investigation findings reflected in the report created 12/27/23.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20231222170043
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
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Administrator is to change lock for R1’s room and confirm R2 does not have any copies of R1’s door key or keys. Administrator to give notice to R2 regarding taking R1 property. Proof of correction (POC) must be sent to: jose.calderon@dss.ca.gov by due date: 02/09/24
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Based on interview, observation, video, and record review the licensee failed to secure R1’s room after viewing R2 entering R1’s room 3 times and taking R1’s personal property which posed a potential health and safety to residents in care.
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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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4