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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 10/06/2021
Date Signed: 10/06/2021 06:40:59 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2021 and conducted by Evaluator Jey Cardenas
COMPLAINT CONTROL NUMBER: 11-AS-20210827103021
FACILITY NAME:GLEN PARK AT LONG BEACHFACILITY NUMBER:
198602134
ADMINISTRATOR:PINK, MARINA EFACILITY TYPE:
740
ADDRESS:1046 E 4TH STTELEPHONE:
(562) 432-7468
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY:208CENSUS: 67DATE:
10/06/2021
UNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Melissa FloresTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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staff not following physicians orders for medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced subsequent complaint visit to the above facility to deliver findings. Upon arrival at the facility LPA conducted a risk assessment over the telephone with staff Bonner; based on the assessment, the facility is clear of Covid-19 infection. LPA met with administrator Melissa Flores and the purpose of the visit was explained.

The investigation consisted of the following: LPA interviewed administrator, Melissa Flores, staff and residents, toured physical plant, and obtained staff/ resident roaster and SIRS for incidents relating to Resident1 and Resident2. R1's Physician Report, MAR (July-August'21) Emergency ID sheet, Drs orders, Appraisal.

Regarding allegation: staff not following physicians orders for medication, It is alleged that staff tried to administer Seroquel and Xanax at the same time trying to "kill” resident. LPA Cardenas interviewed R1 who indicates that residents on a pain management program and has to get pain medication every six
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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-20210827103021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 10/06/2021
NARRATIVE
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hours. R1 states S2 teased and told resident that medication will be dispensed at the end after all the other residents gets their medication. Residents medication is never given on time. LPA asked if resident is still taking Seroquel and Xanax Resident states that S2 tried to give resident two (2) pain pill medications at the same time, LPA asked for that date of the incident, resident doesn’t remember, this was recently.

LPA Cardenas interviewed Melisa Flores who indicates that recently R1 has been making accusations relating to medication, accusations are untrue, resident gets his medication per Dr orders. LPA Cardenas interviewed S2 who indicates that R1 takes psych medication and narcotics, R1 requests both medications be given at the same time. S2 reminds resident to wait before administering the other, because both medications can’t be taken at the same time. S2 indicates he has never threatened resident about medication. Medication is given per doctor’s orders. LPA Cardenas interviewed residents who indicate no issues with medication.

LPA Cardenas reviewed incident report dated 8/19/21, “since 6:30am R1 has been harassing staff, making accusations that resident didn’t receive medication.” LPA Cardenas reviewed MAR and observed medication for R1 was logged when administered.

Based on LPA’s interviews and record reviews, LPA did not find sufficient evidence to support the allegations, Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report to be provided to facility representative

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2021 and conducted by Evaluator Jey Cardenas
COMPLAINT CONTROL NUMBER: 11-AS-20210827103021

FACILITY NAME:GLEN PARK AT LONG BEACHFACILITY NUMBER:
198602134
ADMINISTRATOR:PINK, MARINA EFACILITY TYPE:
740
ADDRESS:1046 E 4TH STTELEPHONE:
(562) 432-7468
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY:208CENSUS: 67DATE:
10/06/2021
UNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Melissa FloresTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident eloped from the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced subsequent complaint visit to the above facility to deliver findings. Upon arrival at the facility LPA conducted a risk assessment over the telephone with staff Bonner; based on the assessment, the facility is clear of Covid-19 infection. LPA met with administrator Melissa Flores and the purpose of the visit was explained.

The investigation consisted of the following: LPA interviewed administrator, Melissa Flores, staff and residents, toured physical plant, and obtained staff/ resident roaster and SIRS for incidents relating to Resident1 and Resident2. R1's Physician Report, MAR (July-August'21) Emergency ID sheet, Drs orders, Appraisal.

Regarding allegation Resident eloped from the facility. LPA reviewed incident report submitted to CCLD report indicates that on 8/15/21 at approximately 7:15am staff were unable to locate R2, staff checked all rooms and reviewed cameras. Upon reviewing cameras R2 was seen leaving the facility with
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20210827103021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
VISIT DATE: 10/06/2021
NARRATIVE
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wheelchair (unassisted/ unsupervised). Police was notified and R2 was later found at 10:10am.

LPA Cardenas interviewed administrator Melissa Flores who indicates that facility staff did their morning rounds for breakfast and didn’t see R2. Resident went missing around the time when staff did their shift change. She states facility has 30 dementia residents varying from mild to severe. Residents reside through the facility and are mixed in with the assisted living residents. There are residents who can leave facility unassisted/ unsupervised, LPA asked how does the staff know who is able to exit the facility with/ without supervision? Melissa showed LPA the residents photos posted at the front office identifying who is unable to leave facility unassisted.

LPA Cardenas reviewed facility video surveillance recording for date 08/14/21 at approximately 6:39am and observed R2 exit through the door that leads from the side of the facility into the garage area; R2 pushed a wheelchair and went around a parked van, resident walked around the van for few minutes until resident made way toward the second door from the garage leading to the outside of the facility.

LPA toured the physical plant and observed the alert system that the facility has in place. There are cameras located at all exits/ entrance, in addition an alarm will sound when a door is opened. When someone exits or enters facility the person at the front desk will see a red light flash, the alarm will sound, and large monitors will expand picture of that assigned exit to show who is entering or exiting. Staff will see who it is and determine if resident leaving can go unassisted. Staff then push a button to stop the alarm sound.

LPA Cardenas interviewed staff#7 (S7) who indicates that on that morning, there was a resident entering around the same time R2 exited. The alert system went off, unfortunately only one camera image will expand and project on the monitor, the other pictures will collapse. S7 didn't see R2 exiting. LPA inquired about the alert systems, (alarm, cameras) staff was unfamiliar with the alert/ camera systems. LPA asked who is not able to leave facility unassisted/ unsupervised, staff states this was second time working graveyard.

Based on LPA’s observations, interviews, and record review(s), the preponderance of evidence standard has been met, therefore the allegations, are found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D. Appeal rights provided.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210827103021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2021
Section Cited
CCR
87705(b)(2)
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Care of Persons with Dementia. Safety measures to address behaviors such as wandering..This requirement not met as evidenced by: During interviews and observations R2 eloped from the facility. This poses a potential health and safety risk to resident in care.
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The licensee will submit a plan of correction outlying steps to take to ensure that Dementia residents do not elope from the facility in the future.
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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.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5