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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 11/06/2024
Date Signed: 11/06/2024 04:56:33 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
10/14/2024 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20241014104543
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: 95DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Jonathan BarriosTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are not meeting resident's dietary needs
INVESTIGATION FINDINGS:
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On 11/06/2024, the department conducted an unannounced subsequent visit to the facility listed above. The department met with Co-Executive Director, Jonathan Barrios, and the purpose of today’s visit was explained.
During today’s visit the department toured the facility, interviewed Staff S9, interviewed Residents R2, R3, and R11, reviewed residents’ medication, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Dietitian Review of menu, electronic Medication Administration Record (eMAR), additional Dietary Order, Nurse Job Description, Medical Technician Job Description, and a copy or resident Admission Agreement.
During a subsequent visit conducted on 10/22/24, the department conducted a facility inspection, interviewed Staff S1-S8, interviewed Residents R1, R4-R10, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician Report, Dietary orders, menus, and staff training.

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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 8
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
10/14/2024 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20241014104543

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: 95DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Jonathan BarriosTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
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9
Staff are threatening resident
Staff did not administer resident's medication
INVESTIGATION FINDINGS:
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On 11/06/2024, the department conducted an unannounced subsequent visit to the facility listed above. The department met with Co-Executive Director, Jonathan Barrios, and the purpose of today’s visit was explained. During today’s visit the department toured the facility, interviewed Staff S9, interviewed Residents R2, R3, and R11, reviewed residents’ medication, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Dietitian Review of menu, electronic Medication Administration Record (eMAR), additional Dietary Order, Nurse Job Description, Medical Technician Job Description, and a copy or resident Admission Agreement.
During a subsequent visit conducted on 10/22/24, the department conducted a facility inspection, interviewed Staff S1-S8, interviewed Residents R1, R4-R10, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician Report, Dietary orders, menus, and staff training.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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 8
Control Number 11-AS-20241014104543
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: 11/06/2024
NARRATIVE
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Allegation: Staff are threatening resident
The complaint allegation alleges that staff have threatened residents if they call and make a report to the Ombudsman.
During the facility tour, LPA observed the Ombudsman and Community Care Licensing poster posted in the hallway near the entrance of the facility.
During record review, LPA received and reviewed an Admission Agreement for residents that states on page 12 that residents have the right “to file a complaint regarding any licensed care facility,” and the information for Community Care Licensing, the Ombudsman office, and local police department information is listed.
During interviews with Staff S1-S9, were asked if residents have the right to file a complaint with the Ombudsman’s Office or Community Care Licensing, nine (9) out of nine (9) stated residents have the right to file complaints. Additionally, during interviews Staff S1-S9, were asked if they have heard of or have threatened a resident if they called the Ombudsman or Community Care Licensing with a complaint, nine (9) out of nine (9) stated they have not heard of staff threatening a resident nor have they threatened a resident who has a complaint.
During interviews with Residents R1- R11, were asked if staff have threatened them if they call the Ombudsman or Community Care Licensing with a complaint, ten (10) out of eleven (11) stated they have not been threatened if they make a complaint to the Ombudsman or Community Care Licensing.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20241014104543
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: 11/06/2024
NARRATIVE
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preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff did not administer resident’s medication
The complaint allegation alleges a resident did not receive their prescribed medication for multiple days.
During record review, LPA received and reviewed Resident R1-R10’s Centrally Stored Medication and electronic Medication Administration Record e(MAR) for the months of September and October 2024. During the facility inspection, the department reviewed the eMAR and residents’ medication for five (5) residents, the department observed five (5) out of five (5) residents eMAR and medication are consistent with properly documented records.
During interviews with Staff S1-S9, were asked if residents receive their medications as prescribed, nine (9) out of nine (9) stated residents receive medications as prescribed.
During interview with Residents R1-R11, were asked if they receive assistance with medication, eleven (11) out of eleven (11) stated they receive assistance with medications. Additionally, during interviews Residents R1-R11 were asked if they receive their medications as prescribed, three (3) out of eleven (11), stated they do not receive their medications as prescribed. Residents R1-R11 were asked if there was a time that they did not receive their prescribed medications, five (5) out of eleven (11) stated there has been times they did not receive their medications.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20241014104543
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: 11/06/2024
NARRATIVE
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During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with Co-Executive Directors, Jonathan Barrios and Gloriella Jara, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20241014104543
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: 11/06/2024
NARRATIVE
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Allegation: Staff are not meeting resident’s dietary needs.
The complaint allegation alleges that the facility does not accommodate residents’ diet regarding food allergies despite having a doctor’s orders.
During record review, the department requested all dietary orders and dietary preferences that the kitchen staff have on file. Upon review, the department observed there was a dietary preference on file for R1 dated 10/25/2022 but no orders. The department inquired further, due to interviews with R1 who stated they provided S1 with a medical document indicating R1’s physician’s dietary order. During the visit, S2 was able to find the dietary order for R1 in a file stating R1’s dietary order dated on 12/21/2023. During an additional interview with S3 and S9, were asked if they have dietary orders regarding R1, two (2) out of two (2) stated we have a dietary preference not an order. Additionally, the department received and reviewed the report from RDs for Healthcare, Inc., Dietitian’s review form Sanitation and food Safety Checklist for Assisted Living conducted on 10/07/24 that states in the comments “Renal diets are eating regular foods.” “Diabetic diets not followed.” and “Not sure the “dietary preference” sheets are being followed.” Additionally, on the form under Food Preparation number “4. Modified diets are served as physician ordered” was marked no.
During the facility inspection of the kitchen, the department observed R1 on the board with dietary preferences stating what they cannot eat and did not observe them on the board with dietary restrictions or orders.
During interviews with Staff S1-S9, were asked if the facility accommodate residents’ dietary physician orders, nine (9) out of nine (9) stated yes, they make
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20241014104543
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: 11/06/2024
NARRATIVE
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accommodations for residents with special dietary orders, restrictions, and preferences.
During interviews with Residents R1-R11, were asked if they have any dietary restrictions or preferences on file, seven (7) out of eleven (11) stated they have dietary order from a physician or dietary preference forms. Additional interview questions were asked to Residents (R1, R4-R9) who have dietary orders or preferences, were asked if their dietary orders and/or preferences were met, two (2) out of seven (7), stated their dietary needs are not met and they are provided with foods they are not supposed to be eating.

During the course of the investigation, the department was able to find evidence to support the allegation. Based on the departments observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.



An exit interview was conducted with Co-Executive Directors, Jonathan Barrios, and a copy of this report and the appeals rights was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20241014104543
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2024
Section Cited
CCR
87555(b)(7)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
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Administrator will review Physicians report and orders and create a binder for the orders to be placed in and update the boards in the kitchen. Administrator will send LPA pictures of the new binder and boards updated in the kitchen, by the POC date via email at Wendy.Gibbs@dss.ca.gov.
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This requirement was not met as evidenced by: based on interview, observation, and
record review the licensee failed to ensure R1 received accomodations for a modified dieat prescribed by residents physician as a medical necessity.
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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: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8