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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 08/01/2024
Date Signed: 08/01/2024 09:56:07 AM

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
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:
08/01/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:ADMIN MICHAEL MENDOZATIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Resident's dietary needs are not being met
INVESTIGATION FINDINGS:
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This report supersedes the report dated 08/10/2023 to clarify the circumstance for the allegations. This report supersedes the previous report the investigation finding for the allegation “Residents dietary needs have are not being met remains Substantiated, the investigation finding for the allegation “Facility is infested with cockroaches.” is Unsubstantiated (please see LIC9099A).
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 (A1)Tonantzin Martinez. LPA 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.
The investigation consisted of the following: On 08/10/2023 LPA Calderon interviewed Administrator (A1), residents (R1-R8), and staff (S1-S4). LPA also obtained and reviewed copies of the following: Pest control reports for (date April – July 2023) and meal plan for residents. LPA also toured common areas of facility. On 02/07/2024 LPA Calderon obtained and reviewed House Call MD Physician order form (date 4/3/2021, 7/22/2022 and 1/31/2023) for R8.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
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 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 08/01/2024
NARRATIVE
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The investigation revealed the following:

Regarding allegation: “Resident dietary needs are not being met.” It is being alleged that residents with diabetes are served the same food as all other residents. Staff interviews conducted indicate the following: A1 indicates that the facility does not provide a separate meal plan for diabetic residents. Resident interviews indicate the following: 7 out of 8 residents indicates that they are diabetic and that the facility does not offer them a diabetic meal plan. R8 indicates, R8 is not diabetic. LPA Calderon reviewed the meal plan for the facility, there is no meal plan found for diabetic residents.

Based interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation “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 plan of correction was developed with Administrator Michael Mendoza. A copy of the Complaint Report and Appeal Rights were provided to Administrator Michael Mendoza.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 6 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 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: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2024
Section Cited
CCR
87555(b)(5)
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87555 General Food Service Requirements (b)The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned... requirement was not met as evidenced by:
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The administrator agreed to create a plan to ensure that a diabetic meal plan is provided to residents. Proof of corrections will be submitted to LPA via email at jose.calederon@dss.ca.gov.

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Based on interviews and record reviews the licensee did not ensure that a diabetic meal plan is provided to 7 out of 8 residents who had diabetes, who poses a potential health, safety, and personal rights risk 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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
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:
08/01/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:ADMIN MICHAEL MENDOZATIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff are injecting insulin for residents
Non-skilled staff are performing manual fecal impaction removal on residents
Facility is infested with cockroaches
Residents are prohibited from using a home health agency of their chosing
INVESTIGATION FINDINGS:
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This report supersedes the report dated 08/10/2023 to clarify the circumstance for the allegations. This report supersedes the previous report the investigation finding the allegation “Facility is infested with cockroaches.” is 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 Administrator (A1), residents (R1-R8), staff (S1-S4). This interview was conducted on 08/10/2023. On 08/10/2023 LPA Calderon obtained and reviewed copies of the following: Pest control reports for (date April-July 2023), meal plan for residents, home health care plan for R1-R8 (need date). On 02/07/2024 LPA Calderon obtained and reviewed House Call MD Physician order form (date 4/3/2021, 7/22/2022 and 1/31/2023) for R8.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 08/01/2024
NARRATIVE
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Regarding Allegation: “Staff are injecting insulin for residents.” It is being alleged that inappropriately skilled staff are injecting residents with insulin. Staff interviews indicate the following: A1 indicates that only a Licensed Vocational Nurse (LVN) is allowed to give insulin injections to residents in care. A1 and S3 indicates that at no time do inappropriately skilled staff inject residents with insulin as they are not trained. S3 added that the home health care nurse comes 2 times per day and injects residents with insulin. Resident interviews revealed the following: 7 out of 8 residents indicates 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 8 residents denied that facility staff has given them the insulin injection. R8 indicates that R8 is not a diabetic.

Regarding Allegation: “Non-skilled staff are performing manual fecal impaction removal on resident.” It is being alleged that manual fecal impaction is being done by non-skilled staff. Staff interviews indicate the following: Steward Home Health Care LVN staff comes to the facility and performs fecal removal on resident R8. A1 states that no facility staff have the training to perform the fecal removal on residents in care, and no facility staff would be allowed to perform the fecal removal on any resident in care. Resident interviews revealed the following: S3 confirmed that the Steward 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. Seven out of eight residents do not have fecal removal done by staff or home health care nurses. Resident interviews revealed the following: R8 indicates that Steward Home Health Care LVN performs the fecal removal, and no staff has ever performed the fecal removal on R8. Record reviews indicate the following: House Call MD (dated 4/2/2021, 7/22/2022, 1/31/2023) indicates that R8 was serviced for catheter, decompaction stool and UTI.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 08/01/2024
NARRATIVE
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Regarding Allegation: Facility is infested with cockroaches. It is being alleged that there is a cockroach infestation all over the facility. Staff interviews indicate the following: The pest control company “All Out Extermination” comes one time per month and sprays for pests in the common areas. Staff also addresses any reports of roaches and will spray any arear where roaches are found. S1-S4. 4 out of 4 staff interviewed (S1-S4) indicates that there are water roaches that come from the water pipes and in the hallway, and they spray for roaches weekly. Resident interviews revealed the following: R1 and R8 indicates that there are no roach problems. 6 out of 8 resident indicates that they although they have seen roaches in the facility the pest control does spray for insects and staff also sprays for roaches. LPA observations indicate the following: During the investigation LPA Calderon did not see the presence of roaches in the facility. Record Reviews indicate the following: “All Out Extermination” pest control report (dated April to July 2023), roach bait placed in common areas. There are no mention of roaches found by pest control.

Regarding Allegation: Residents are prohibited from using a home health agency of their choosing. It is being alleged that the facility is only allowing one home health agency to provide services to the residents in care. Staff interviews indicate the following: A1 indicates that residents are given 5 options for home health care services and one option is Steward Home Health Care, and that resident are not prohibited from using other home health care companies. Resident interviews revealed the following: 7 out of 8 residents did not know the name of their home health care company. Record Reviews indicate the following: 30 out of 86 residents have Home Health Care services of which 16 out 30 residents receive home health services through Steward Home Health Care and 14 out of 30 receive Home Health Care services from other companies.

Based on interviews, observations, and record reviews, the preponderance of evidence standard has not been met; The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. 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” and “facility is infested with cockroaches” is found to be Unsubstantiated. No deficiencies were cited.

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

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6