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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 01/10/2025
Date Signed: 02/20/2025 02:44:55 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/03/2025 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20250103134517
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: 97DATE:
01/10/2025
UNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff did not dispense medications to resident as prescribed
INVESTIGATION FINDINGS:
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*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 1/10/25.

On 1/10/25, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Office Manager, Shanick Jackson and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 1/10/25, Licensing Program Analyst (LPA) Felisa Shirley requested and received copies of the following: LIC 500, Resident Roster, copies of resident file, MAR for December 2024 and January 2025 and Med Tech Certifications.

The investigation revealed the following:
Con'd on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
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 5
Control Number 11-AS-20250103134517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/10/2025
NARRATIVE
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Allegation: Facility staff did not dispense medications to resident as prescribed

On 1/10/25, LPA Felisa Shirley conducted a review of resident’s service file including Medication Administration Records (MAR). Records revealed that there three medications with dates with no entries by made by Med Techs and there are three prescribed medications that were not dispensed and still in the bubble pack.

LPA Shirley interviewed staff-1 thru staff-7 (S-1 thru S-7). LPA asked, does staff dispense medications to residents as prescribed? Of those interviewed, 7 out of 7 answered yes. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, do you receive your medications as prescribed by your doctor?” Of those interviewed, 6 out of 7 answered yes and 1 answered no. According to the information gathered there is sufficient evidence to support the allegation mentioned above.



Based on interview and record review the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8.

Deficiencies are issued and an exit interview is conducted with Melissa Flores. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20250103134517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(a) 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. (4) The licensee shall assist residents with self-administered medications as needed.


This requirement was not met as evidenced by:
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Licensee will submit plan informing the department medication training has been performed with all staff. A written proof of correction must included along with date, time and participants names. Correction must be submitted by due date: 3/6/25 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016
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Based on interviews and records review, records revealed that there were three medications with dates with no entries made by Med Techs for R-1 and there were three prescribed medications that were not dispensed and still in the bubble pack. This action poses as an immediate health and safety risk to persons 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: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/03/2025 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20250103134517

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: 97DATE:
01/10/2025
UNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Shanick Jackson, Office ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
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9
Facility staff spoke inappropriately to resident
INVESTIGATION FINDINGS:
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3
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5
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7
8
9
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11
12
13
On 1/10/25, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Office Manager, Shanick Jackson and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 1/10/25, Licensing Program Analyst (LPA) Felisa Shirley requested and received copies of the following: LIC 500, Resident Roster, copies of resident file, MAR for December 2024 and January 2025 and Med Tech Certifications.

The investigation revealed the following:

Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
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 5
Control Number 11-AS-20250103134517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/10/2025
NARRATIVE
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Allegation: Facility staff spoke inappropriately to resident

It is being reported that R-1 was spoken to inappropriately by management. On 1/10/25, LPA spoke with R-1 and resident stated that they were told that they had to make an appointment to speak to management, that this is not a medical facility and maybe did not belong in this facility.

LPA Shirley interviewed staff-1 thru staff-7 (S-1 thru S-7). LPA asked, do you speak inappropriately to residents? Of those interviewed, 7 out of 7 answered no. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, has staff or management spoken to you inappropriately?” Of those interviewed, 6 out of 7 answered no, and 1 answered yes. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Facility staff spoke inappropriately to resident,” therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of the LIC 9099 report was provided to Melissa Flores, Executive Director.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5