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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 08/10/2023
Date Signed: 08/02/2024 03:39:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230802112635
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: 86DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:ASST ADMIN TONZATZIN MARTINEZTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is infested with cockroaches
Resident's dietary needs are not being met
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
THIS REPORT SUPERSEDES THE REPORT DATED 08/10/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: SUBSTANTIATED
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Glen Park at Long Beach Facility on 08/10/2023 and was greeted by Assistant Administrator Tonantzin Martinez (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
During this investigation, LPA Calderon interviewed A1, R1-R8, S1-S4. This interview was conducted on 08/10/2023. On 08/10/2023 LPA Calderon requested copies of the following: Pest control reports for 3 months, home health reports for R1-R8, needs and service plan for C8, LVN information. On 02/07/2024 LPA Calderon obtained and reviewed House Call MD Physician order form (date 4/3/2021, 7/22/2022) for R8. On 08/10/2023 LPA Calderon toured common areas of facility.
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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 6
Control Number 11-AS-20230802112635
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/10/2023
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 Allegation #1: Facility is infested with cockroaches.

This complaint alleged facility has a pest control problem. LPA Calderon conducted an interview with A1. A1 relays pest control comes one time per month and sprays for pests in the common areas. A1 relays that staff also will address any reports of roaches and will spray for roaches. LPA Calderon conducted an interview with S1-S4. 4 out of 4 staff relays that there are water roaches that come from the water pipes. 4 out of 4 staff state that they have seen roaches in the hallway, and they also spray roaches. LPA Calderon conducted an interview with R1-R8. R1 and R8 relay that there are no roach problems. R2-R7 relays that they have seen roaches in the hallway, water pipes and inside their bathrooms. R2-R8 relay that pest control does spray for insects and staff also sprays for roaches. On 08/10/2023 LPA Calderon toured common areas of facility; LPA Calderon did not see any roaches.

Regarding Allegation #2: Resident dietary needs are not being met.

This complaint alleged residents’ dietary needs are not being met. LPA Calderon conducted an interview with A1. A1 relays that the facility does not provide a separate meal plan for diabetic residents. LPA Calderon conducted an interview with R1-R8. R1 states that R1 us diabetic and the facility does not offer a diabetic meal plan. R2-R8 relay that they are diabetic, and the facility does not offer residents a meal plan for diabetic residents. LPA Calderon reviewed the meal plan for the facility, there is no meal plan found for diabetic residents.

Based on LPA Calderon observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegations “facility is infested with cockroaches” “residents dietary needs are not being met” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Assistant Administrator Tonantzin Martinez (A1).

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20230802112635
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2023
Section Cited
CCR
80087(a)(1)
1
2
3
4
5
6
7
87303Maintenance 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:
1
2
3
4
5
6
7
Administrator will provide specific notes from pest control as to where and what type of pest they sprayed for and what plan do they have for future chemical spraying to LPA by 8/25/23.
8
9
10
11
12
13
14
Based on interview, observation, and record review the licensee failed to ensure that the facility is free of, cockroaches as reported to LPA on 8/10/23, per 1 of 3 staff and 8 of 8 clients interviewed. Roaches were located in the rooms and hallways, which posed a Potential health and safety to residents in care.
8
9
10
11
12
13
14
Type B
08/25/2023
Section Cited
CCR
87555(b)(7)
1
2
3
4
5
6
7
87555 General Food Service Requirements (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by:

1
2
3
4
5
6
7
Licensee needs to provide 2 meal plans for residents in care. Need to provide a general meal plan and a diabetic meal plan by the POC date to LPA Calderon
8
9
10
11
12
13
14
Based on interview, observation, and record review the licensee failed to ensure that the facility has a diabetic meal plan for residents in care as reported to LPA on 8/10/23. Per 3 of 3 staff and 7 of 8 residents facility did not provide a diabetic menu meal plan option which poses a Potential l health and safety to residents in care.
8
9
10
11
12
13
14
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: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230802112635

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: 86DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:ASST ADMIN TONZATZIN MARTINEZTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are injecting insulin for residents
Non-skilled staff are performing manual fecal impaction removal on residents
Residents are prohibited from using a home health agency of their chosing
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
THIS REPORT SUPERSEDES THE REPORT DATED 08/10/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR 8THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: UNSUBSTANTIATED
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Glen Park at Long Beach on 08/10/2023 and was greeted by Assistant Administrator Tonantzin Martinez (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
During this investigation, LPA Calderon interviewed A1, R1-R8, S1-S4. This interview was conducted on 08/10/2023. On 08/10/2023 LPA Calderon requested copies of the following: Pest control reports for 3 months, meal plan for diabetic residents, needs and service plan for R8, home health care plan for R1-R8. On 02/07/2024 LPA Calderon obtained and reviewed House Call MD Physician order form (date 4/3/2021, 7/22/2022) for R8.
The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20230802112635
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/10/2023
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 Allegation #1: Staff are injecting insulin for residents.

This complaint alleged staff are injecting residents with insulin. LPA Calderon conducted an interview with A1. A1 relays that only a LVN is allowed to give insulin injections to residents in care. A1 relays that at no time do staff ever inject residents with insulin as they are not trained. LPA Calderon conducted an interview with S3. S3 relays that at no time does any facility staff other than a trained LVN inject insulin residents in care and that the home health care nurse comes 2 times per day and this person takes care of resident’s insulin needs. LPA Calderon conducted an interview with R1-R8. 7 out of 8 residents relay that they are diabetic and that the nurse with home health care services come to the facility 2 times per day and gives them their insulin injections. 7 out of 8 residents relay that no facility staff has ever given them the insulin injection. R8 relays that R8 is not a diabetic. Reviewed House Call MD (date 4/2/2021, 7/22/2022) House Call MD serviced R8 for catheter, compaction stool and UTI

Regarding Allegation #2: Non-skilled staff are performing manual fecal impaction removal on resident.

This complaint alleged non-skilled staff are performing fecal removal on resident in care. LPA Calderon conducted an interview with A1. A1 states that Steward Home Health Care LVN staff comes to the facility and performs fecal removal on R8. A1 states that no facility staff have the training to perform the fecal removal on residents in care. A1 relays that no facility staff would be allowed to perform the fecal removal on any resident in care. LPA Calderon conducted an interview with S3. S3 relays that the home health care LVN performs the fecal removal on R8, and no facility staff would be allowed to perform the fecal removal on any resident in care. LPA Calderon conducted an interview with R1-R8. 7 out of 8 residents do not have fecal removal done by staff or home health care nurses. LPA Calderon conducted an interview with R8. R8 relays that Steward Home Health Care LVN performs the fecal removal, and no staff has ever performed the fecal removal on R8. R8 relays that R8 is not a diabetic. Reviewed House Call MD (date 4/2/2021, 7/22/2022, 1/31/2023) House Call MD serviced R8 for catheter, compaction stool and UTI.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20230802112635
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/10/2023
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 Allegation #3: Residents are prohibited from using a home health agency of their choosing.

This complaint alleged facility did not allow residents to choose their own health care plan. LPA Calderon conducted an interview with A1. A1 relays that residents are given 5 options for home health care services and one option is Steward Home Health Care. A1 relays that resident is not prohibited from using another home health care company. LPA Calderon conducted an interview with R1-R8. 7 out of 8 residents did not know the name of the home health care company LVN worked for. R8 relays that R8 understood the name of the home health care company LVN worked for. On 08/10/2023 LPA Calderon reviewed the home health care provider's information. 30 total residents have Home Health Care (HHC) services of which 16 have Steward and other have HHC services options. R8 relays that R8 is not a diabetic. Reviewed HouseCall MD (date 4/2/2021, 7/22/2022, 1/31/2023) HouseCall MD serviced R8 for catheter, decompaction stool and UTI.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “staff are injecting insulin for residents” “non-skilled staff are performing manual fecal impaction removal on resident” “resident are prohibited from using a home health agency of their choosing” is found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Assistant Administrator Tonantzin Martinez (A1).

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6