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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602134
Report Date: 09/27/2024
Date Signed: 09/27/2024 09:03:18 AM


Document Has Been Signed on 09/27/2024 09:03 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 BEACHFACILITY NUMBER:
198602134
ADMINISTRATOR:MICHAEL MENDOZAFACILITY TYPE:
740
ADDRESS:1046 E 4TH STTELEPHONE:
(562) 432-7468
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY:208CENSUS: DATE:
09/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Tyshima Bonner, Office ManagerTIME COMPLETED:
09:15 AM
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On Friday, September 27, 2024 at 8:25am LPA Zina Brown made an unannounced visit to facility to amend a report from May 30, 2024.

LPA Zina Brown spoke with Michael Mendoza for the phone to inform him of the complaint investigation report - Unsubstantiated (visit date: May 30, 2024).
Executive Director Michael Mendoza gave Office Manager Tyshima Bonner permission to off sign on the document.

No deficiencies cited were cited during today.

Exit interview was conducted with Tyshima Bonner and a copy of the report.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Zina BrownTELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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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