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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 11/07/2024
Date Signed: 11/16/2024 03:05:56 PM

Unsubstantiated


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
01/18/2024 and conducted by Evaluator Pamela Bunker
COMPLAINT CONTROL NUMBER: 11-AS-20240118125422
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:
11/07/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jonathan BarriosTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff do not ensure a comfortable living environment for residents
Staff do not prevent residents from entering other resident's rooms
Staff do not meet resident’s modified dietary needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Thursday, November 07, 2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. The department then met with Co-Executive Director Jonathan Barrios and explained that the purpose of the visit was to complete the 10-day complaint investigation initiated on Monday, January 22, 2024.
The investigation consisted of the following: During the course of the investigation the department conducted interviews with staff members 1-4 (1-4) and residents 1-9 (R1-9). The department posed questions pertinent to the nature of the complaint. The department requested and reviewed resident 1's records. The department obtained copies of the following documents: The Department obtained copies of the following documents: Staff and residents roster, admission agreement, physician's report, medical assessment, medication administration records (MARs), consent forms, replacement appraisal information, identification and emergency information, appraisal needs and service plan, safeguards for property/valuables, calendar menus, special incident reports. See continued LIC9099-C page 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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-20240118125422
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: 11/07/2024
NARRATIVE
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Continued LIC9099-C page 2

Training on reporting dependent adult and elder abuse, staff in-service training, and ongoing staff training.

Allegation: Staff do not ensure a comfortable living environment for residents
The department interviewed staff members 1-4 (S1-S4) and residents 1-9 (R1-R9) they all stated the facility staff provides residents with a comfortable living environment and meets their daily care needs. S1-S4 and R1-R9 stated that residents with dementia do not walk up and down the halls at night screaming or banging on other residents' doors. S1-S4 and R1-R9 denied the allegation.

Allegation: Staff do not prevent residents from entering other resident's rooms
The department interviewed staff members 1-4 (S1-S4) and residents 1-9 (R1-R9) who stated the facility staff take measures to prevent residents from entering other residents' rooms. S1-S4 and R1-R9 explained that room doors automatically lock when residents leave their rooms and require a key to unlock the door. They also stated that female residents are not seen running down the hallway screaming, "Get out of my room!" S1-S4 and R1-R9 denied the allegation.

Allegation: Staff do not meet residents’ modified dietary needs.
The department interviewed staff members 1-4 (S1-S4). All staff stated that the cook follows a meal plan and serves nutritious meals three times a day, seven days a week. S1-S4 explained that if a resident is on a modified diet prescribed by a physician as a medical necessity, staff follow the physician’s orders.
S1-S4 stated that the resident in question was not on a restricted or modified diet. They also stated that residents can request substitutions if they do not like the meals served. S3 noted that while not all residents may love every meal, the menu offers a variety of food options to accommodate preferences. S3 reiterated that she follows the meal plan and ensures nutritious meals are served daily. The department also interviewed residents R1-R9. R1 stated that the facility served food to which he was allergic and described the food as not good or nutritious. R2-R9 reported that the food was delicious and that they had no issues with the meals provided. S1-S4 and R2-R9 also stated that residents have alternative meal options if they dislike what is served. The department reviewed the facility’s meal plan and determined that the total daily diet meets the quality and quantity necessary to meet residents’ needs. S1-S4 and R2-R9 denied the allegation. See continued LIC9099-C page 3
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20240118125422
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: 11/07/2024
NARRATIVE
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Continued LIC9099-C page 4

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC9099, and LIC9099-Cs was provided to the Co-Executive Director Jonathan Barrios.

There were no deficiencies cited.

An exit interview was conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 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, 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
01/18/2024 and conducted by Evaluator Pamela Bunker
COMPLAINT CONTROL NUMBER: 11-AS-20240118125422

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:
11/07/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
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7
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9
Allegation: Staff did not safeguard the resident’s personal belongings
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Thursday, November 07, 2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. The department then met with Co-Executive Director Jonathan Barrios and explained that the purpose of the visit was to complete the 10-day complaint investigation initiated on Monday, January 22, 2024.

The investigation consisted of the following: During the course of the investigation the department conducted interviews with staff members 1-4 (1-4) and residents 1-9 (R1-9). The department posed questions pertinent to the nature of the complaint. The department requested and reviewed resident 1's records. The department obtained copies of the following documents: The personnel report, resident's roster, appraisal/needs and service plan, replacement appraisal information, special incident report, safeguards for property, and valuables. On 01/22/2024 Administrator Michael Mendoza, Maintenance worker Geo Grajeda, and LPA Bunker observed the air conditioner in the resident's room. See continued LIC9099-C page 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20240118125422
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: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The deficiency was corrected prior to the complaint visit.
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There was a water leak on the right side of the resident's bed caused by the air conditioning unit, which dripped water onto the bed, soaking the linens and mattress.

The violation poses a potential health and safety 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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 11-AS-20240118125422
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: 11/07/2024
NARRATIVE
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Continued LIC9099-C page 2

On 11/07/2024, Co-Executive Director Jonathan Barrios and LPA observed the air conditioning unit in room 220 was operational and in good repair.

The Department obtained copies of the following documents: The staff and residents roster, admission agreement, physician's report, medical assessment, medication administration records (MARs), consent forms, replacement appraisal information, identification and emergency information, appraisal needs and service plan, safeguards for property/valuables, special incident report, staff in-service training, ongoing staff training, a video, and photos of room 220 air conditioner unit resident bed, and mattress.

Allegation: Staff did not safeguard the resident’s personal belongings.
Staff members S1–S4 and residents R2–R9 stated that facility staff are safeguarding residents’ personal belongings. S1 and S2 acknowledged that water was dripping from the air conditioning (AC) unit in the resident’s room, located on the right side of the resident’s bed. They stated that the water had soaked the linens and mattress. S1 and S2 also confirmed that the AC unit was repaired, and the resident’s mattress is now dry and undamaged. Resident R1 provided a video and photos as evidence showing water dripping from the AC unit onto the bed, and wetting the linens and mattress. Residents R2–R9 reported that their AC units were in good working condition and did not experience any water leakage. S3 stated that she had no knowledge of the AC unit leaking water. S4 indicated that he was not employed at the facility during the time of the alleged incident and had no knowledge of the matter. During an inspection of R1’s room, the mattress was observed to be dry and in good condition, with no visible need for replacement.

Based on the Department's observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

Appeal rights were discussed, and copies of the Complaint Investigation Report LIC9099-A, LIC9099-C, and LIC9099-D were provided to Co-Executive Director Jonathan Barrios.

An exit interview was conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6