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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 10/25/2024
Date Signed: 10/25/2024 03:21:24 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, 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
07/02/2024 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240702154711
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: 94DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Executive Director Michael MendozaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained fractures due to staff dropping resident while transferring.
INVESTIGATION FINDINGS:
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The investigation consisted of the following: On 07/05/2024 Community Care Licensing Division (CCLD) staff requested records which include Staff Roster, Resident Roster, incident report(s), 4 months of past pest control invoice(s) and two (2) residents Admission Agreements. On 07/15/2024 CCLD staff reviewed records, toured the kitchen and interviewed 8 staff members which included the Executive Director, Memory Care Director, Cook, LVN, (2) MedTechs, Front Desk, and Care Partner. On 07/25/2024 CCLD staff reviewed the register of residents and interviewed five (5) residents. On 08/16/24, CCLD staff interviewed four residents. On 10/25/24, CCLD staff interviewed attempted to one resident and delivered findings. The investigation revealed the following: Regarding the allegation "Resident sustained fractures due to staff dropping resident while transferring,” It is being alleged that staff did not provide proper level of assistance when assisting residents which resulted to resident’s injuries.

Continue to LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 3
Control Number 11-AS-20240702154711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 10/25/2024
NARRATIVE
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 Record reviews revealed the following: Resident records indicate that R1 requires assistance in transferring from chair to bed and has risks of falls. Incident reports indicate that on 08/12/22 around 2:15 PM an agency caregiver helped R1 transfer from R1’s wheelchair to the bed when R1 fell. R1 indicated that during the incident the "small lady" caregiver who was assisting R1 could not support R1’s weight, R1 lost balance, and fell during the process. The incident report revealed that Resident #2 (R2) witnessed the fall and indicated the caregiver tried to help R1 by moving R1's foot that would not move. Without supporting R1's balance, when R1's foot was pulled forward, R1 fell down. Hospital medical records indicate that on 08/13/2022, R1 was hospitalized at St. Mary’s Medical Center and during R1’s evaluation, it was discovered R1 had fractured her leg in two different places which required surgery. Interviews revealed the following: Staff indicated that the caregiver who assisted R1 during the fall was employed with an outside agency. Two out of four residents indicated they have witnessed staff struggle with residents who need transfer assistance. One out of the two residents indicated that they have fallen a couple of times while in care at the facility.

Regarding the allegation “Resident sustained fractures due to staff dropping resident while transferring,” based on record reviews and interviews, the preponderance of evidence has been met therefore the allegation is Substantiated.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49 (e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including but not limited to, the following: loss of consciousness, concussion, bone fracture, protracted loss or impairment of anybody member or organ, a wound requiring extensive suturing, and serious disfigurement.”

An exit interview was conducted and a copy of this report and appeal rights was provided to with Executive Director Michael Mendoza.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240702154711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2024
Section Cited
CCR
87468.2(a)(4)
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(a) In addition to the rights listed in section 87468.1... residents... shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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The Administrator will email a plan of correction to regina.cloyd@dss.ca.gov by the POC due date.
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This requirement is not met as evidence by:
Based on interviews and record review the licensee did not ensure R1's individual needs were met and delivered by staff during transfer which posed an immediate health, safety, and personal rights risk to R1.
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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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
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