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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 02/27/2025
Date Signed: 02/27/2025 12:53:39 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
12/10/2024 and conducted by Evaluator Zina Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241210135158
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:
02/27/2025
UNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Rafael Silva, Quality Assurance Director.TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident did not receive medication as prescribed.
INVESTIGATION FINDINGS:
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On 02/27/2024 at 10:45 am, Licensing Program Analyst (LPA) Zina Brown and Licensing Program Manager (LPM) Janae Hammond conducted a subsequent visit in order to deliver investigation findings. LPA/LPM met with Rafael Silva, Quality Assurance Director.and explained the purpose of the visit .

The investigation consisted of the following: On 12/16/2024 LPA ZinaBrown interviewed the Administrator (A1), Staff #2 - Staff #6 (S2 - S6) and Resident # 1 - Resident #9 (R1 – R9). LPA requested resident/staff Roster, resident files for Resident #1 - Resident #9 (R1 - R9) such as LIC 601 / Pre-Placement Appraisal/ Functional Capability Assessment/Medication List/ Admission Agreement/ Physician Report, proof of Staff Training (med-tech/caregiver) – Initial Training and ongoing training, timecards for staff (October 2024 – December 2024), list of incontinence residents. On 1/21/25 at 2:48pm LPA interviewed Staff #1. On 1/21/24 at 8:47am LPA interviewed Resident #10. On 1/24/25 at 9:05am LPA/LPM interviewed Staff #7.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
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 6
Control Number 11-AS-20241210135158
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: 02/27/2025
NARRATIVE
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The investigation revealed the following:

Allegation: Resident did not receive medication as prescribed.

It was alleged there are multiple medication errors including some residents are not receiving their medications. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied being aware of any residents not receiving their medications. On 12/16/2024 between 11:45am - 1:00 pm and 1/21/25 2:48pm and 1/24/25 at 9:05 am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 3 of 7 staff interviewed denied the allegation; 3 of 7 staff interviewed were unable to answer the questions since they do not administer medications and 1 out of 7 staff confirmed the allegation. On 12/16/2024 between 10:00am - 11:30am and 1/22/2025 8:47am - 9:38am and 1/21/25 8:47am, LPA/LPM interviewed Residents #1-10. 6 of 10 residents denied the allegation; 3 of 10 residents confirmed the allegation and 1 of 10 residents stated they sometimes don’t receive medications. LPA/LPM reviewed 9 residents Medication Administration Records (MAR) and medications, 9 out of 9 reviewed had medication errors. 8 of 9 medications were not in the medication was not in the bubbled pack and the MAR was not signed;1 of 9 residents MAR is not signed from 12/1/24-12/16/24 for routine medications; 3 of 9 residents medication was still in the bubble pack (not given) and the MAR was not signed.

Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted, appeal rights explained, and a copy of this report was provided to Rafael Silva, Quality Assurance Director.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 5 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, 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
12/10/2024 and conducted by Evaluator Zina Brown
COMPLAINT CONTROL NUMBER: 11-AS-20241210135158

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:
02/27/2025
UNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Rafael Silva, Quality Assurance Director.TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Unqualified staff is administering insulin injections to residents.
Facility staff are stealing residents medication.
Illegal eviction.
Facility charging residents for services without consent.
INVESTIGATION FINDINGS:
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On 02/27/2025 at 0:00am, Licensing Program Analyst (LPA) Zina Brown and Licensing Program Manager (LPM) Janae Hammond conducted a subsequent visit in order to deliver investigation findings. LPA/LPM met with Rafael Silva, Quality Assurance Director. and explained the purpose of the visit .

The investigation consisted of the following: On 12/16/2024 LPA Brown interviewed the Administrator (A1), Staff #2 - Staff #6 (S2 - S6) and Resident # 1 - Resident #9 (R1 – R9). LPA requested resident/staff Roster, resident files for Resident #1 - Resident #9 (R1 - R9) such as LIC 601 / Pre-Placement Appraisal/ Functional Capability Assessment/Medication List/ Admission Agreement/ Physician Report, proof of Staff Training (med-tech/caregiver) – Initial Training and ongoing training, timecards for staff (October 2024 – December 2024), list of incontinence residents. On 1/21/25 at 2:48pm LPA interviewed Staff #1. On 1/21/24 at 8:47am LPA interviewed Resident #10. On 1/24/25 at 9:05am LPA/LPM interviewed Staff #7.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
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 6
Control Number 11-AS-20241210135158
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: 02/27/2025
NARRATIVE
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The investigation revealed the following:

Allegation: Unqualified staff is administering insulin injections to residents.
It is alleged appropriate skilled professionals are not administering insulin injections to diabetic resident on the weekend when the LVN is not working. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 stated LVN administers insulin Monday-Friday and med tech administer insulin hand over hand to residents. On 12/16/2024 between 11:45am -1:00 pm and 1/21/25 2:48pm and 1/24/25 at 9:05am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 2 of 7 staff interviewed stated the LVN administers insulin and med techs prepare the medication and the resident self administers; 2 of 7 state the LVN administers insulin and comes in to assist as needed on the weekend; 2 of 7 state they have witnesses the LVN and med techs administer insulin and 1 of 7 state the LVN administers insulin and they have never witnessed med techs administer insulin. On 12/16/2024 between 10:00am-11:30am and 1/21/2025 8:47am - 9:38am, LPA/LPM interviewed Residents #1-10. 9 of 10 residents stated the LVN administers insulin and 1 of 10 stated the LVN and med techs administer insulin.

Allegation: Facility staff are stealing residents medication.


It is alleged staff are stealing residents Narcotic medications. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied being aware of staff stealing medications. On 12/16/2024 between 11:45am - 1:00 pm, 1/21/25 2:48pm and 1/24/25 at 9:05am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 7 of 7 staff interviewed denied the allegation. On 12/16/2024 between 10:00am - 11:30am and 1/21/2025 8:47am-9:38am, LPA/LPM interviewed Residents #1-10. 10 of 10 residents denied the allegation.

Report continues on LIC 9099-C page.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20241210135158
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: 02/27/2025
NARRATIVE
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Allegation: Illegal Eviction
It was alleged R8 was issued, and eviction notice and was put outside the facility on the streets. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied R8 was issued an eviction notice but stated the facility intends to issue one. On 12/16/2024 between 11:45am-1:00 pm,1/21/25 2:48pm and 1/24/25 at 9:05am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 4 of 7 staff interviewed denied the allegation; 2 of 7 staff are aware of residents being evicted in the past. 1 out of 7 staff stated R8 was talked to about his behavior but was not issued an eviction notice. On 12/16/2024 between 10:00am-11:30am and 1/21/2025 8:47am - 9:38am, LPA/LPM interviewed Residents #1-10. 9 of 10 residents denied the allegation; 1 out of 10 residents confirmed receiving a verbal eviction. LPA/LPM conducted a file review and did not observe and eviction notices on file for R8.

Allegation: Facility charging residents for services without consent.
It is alleged facility does weekly COVID testing and residents insurance is being billed without consent from the residents or responsible parties. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied the allegation and stated the facility pays for COVID testing. On 12/16/2024 between 11:45am-1:00 pm, 1/22/25 2:48pm and 1/24/25 at 9:05am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 7 of 7 staff interviewed denied the allegation. On 12/16/2024 between 10:00am-11:30am and 1/21/2025 8:47am-9:38am, LPA/LPM interviewed Residents #1-10. 8 of 10 residents denied the allegation; 2 out of 10 residents confirmed the allegation. LPA/LPM conducted a review of records and did not observe any evidence that residents are being charged for COVID testing.

Based on the records reviewed, interviews conducted and Observations the allegation are Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with Rafael Silva, Quality Assurance Director and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20241210135158
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: 02/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2025
Section Cited
CCR
87465(a)(6)
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87465 Incidental Medical and Dental Care
Each facility shall develop a planned routine of medical and dental care and assisting in obtaining such care.When requested by the physician or Department, the facility shall maintain a record of centrally stored medication dosages.
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The Executive Director will conduct in-service training and implement a plan to check medications regularly to prevent discrepancies. Proof will be submitted via email at zina.brown@dss.ca.gov by the POC due date.
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Based on observation, interview, and record review, the licensee did not comply with the cited section. During medication reviews, LPA observed MAR documentation showing resident didnt receive their medication which posing a potential health, safety, or personal rights risk.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6