198602134-9-27-2024-11-AS-ZBRN-D9GTYV-20240926150921

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602134
Report Date: 09/26/2024
Date Signed: 09/27/2024 10:53:38 AM

Document Has Been Signed on 09/27/2024 10:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	MICHAEL MENDOZA		FACILITY TYPE:	740
ADDRESS:	1046 E 4TH ST		TELEPHONE:	(562) 432-7468
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY:	208	CENSUS: 100	DATE:	09/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Michael Mendoza, Administrator		TIME COMPLETED:	03:30 PM

NARRATIVE

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On 09/26/2024 at 09:00am, Licensing Program Analyst (LPA) Zina Brown and Lizeth Villegas conducted an unannounced annual visit to the above facility. LPAs met with Michael Mendoza , Administrator and the purpose of the visit was discussed. Facility is licensed to serve 4 ambulatory, 174 non-ambulatory residents and 30 bedridden residents. 17 of the residents are diagnosed with dementia and 32 of the resident are incontinent. Facility fees are current.

The two-story commercial building consists of one hundred (100) resident bedrooms, multiple resident bathrooms, three (3) common bathrooms, dining room, commercial kitchen, staff room, office area, media room, garden area, washer and dryer/ storage area, backyard with umbrella with table and chairs. There is a Dementia unit that was inspected and approved by the department.

At 11:00am, LPA Zina Brown went on a tour with Michael Mendoza of the inside and outside of facility grounds. The resident bedrooms had the required furniture, pull style call buttons, bed linens and closet/drawer space to accommodate each resident comfortably. The 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, water temperature measured at 114.3 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

The commercial kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors and carbon monoxide were working properly, and fire extinguisher was fully charged. First Aid kit was available. There are no bodies of water, security bars, nor fire arms are on the premises.

A discrepancy was observed and documented on 809-D page

Exit interview conducted, appeal rights explained, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Zina Brown	TELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/27/2024 10:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(6)

87465 Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above as during medication reviews, LPA observed documentation on the MAR indicating if residents refused or missed taking medication throughout the week which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	The executive director will ensure a in-service training regard medication documentation is completed by POC due date and provide proof of in-service training for all staff via email at zina.brown@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Zina Brown	TELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC809 (FAS) - (06/04)

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