198602134-8-9-2021-11-AS-MCAA-C7TVXQ-20211015164956

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 08/09/2021
Date Signed: 08/09/2021 03:39:10 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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2021 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20210805101839

FACILITY NAME:	GLEN PARK AT LONG BEACH		FACILITY NUMBER:	198602134
ADMINISTRATOR:	PINK, MARINA E		FACILITY TYPE:	740
ADDRESS:	1046 E 4TH ST		TELEPHONE:	(562) 432-7468
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY:	208	CENSUS:	DATE:	08/09/2021
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Melissa Flores		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff dispensed medication to resident without a prescription
Resident sustained a fall while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 08/09/21 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced complaint visit regarding the allegations above. LPA was met by Facility Administrator Melissa Flores and the purpose of the visit was explained.

The investigation consisted of: Resident Interviews, Staff interviews, Record Review, and requested Pertinent, and supplement documents regarding the investigation.

Regarding Allegation: Facility staff dispensed medication to resident without a prescription.
Reporting Party stated that Resident 1 (R1) was in the hospital due a fall. The toxicology report showed that (R1) had tested positive for Fentanyl. The facility was contacted and stated that they do not carry
That type of controlled medication. The LPA conducted a record review of R1’s Medication Record and did not observe any prescription for fentanyl. LPA toured Medication room and did not observe any prescribed fentanyl medications in the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

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 2

Control Number 11-AS-20210805101839

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
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN PARK AT LONG BEACH	FACILITY NUMBER: 198602134
	VISIT DATE: 08/09/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Facility Administrator stated that that no resident in
Care is prescribed that type of medication. The LPA conducted interviews with residents in care, some of which are on controlled medications. All resident, including R1 Generally stated that they receive their prescribed medications and have not received anything that was not prescribed to them.
Based on LPA Record Review, Observation, and Interviews the LPA finds that : Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding Allegation: Resident sustained a fall while in care.

Reporting Party stated that the resident has had 3 documented falls dating back to 2020. R1’s last fall

Was on 08/01/21. R1 was admitted to the hospital. Prior to the last fall, On 07/13/21 R1 was placed into hospice care. The facility conducted a Re-assessment /Needs and services plan on 07/29/21. The plan indicated R1 has a history of falls, and set a new plan in place, which included R1 being placed on Hospice, and bed rails being added to the bed, and discussed one on one care with family, or higher level of care to meet R1's needs. Family wants to keep R1 at the facility. . LPA conducted interviews with other residents in care, whom are both Ambulatory, and Non-Ambulatory. Residents 1-7 generally stated that they have not had any falls while in care.

Based on LPA interview, and record review, the LPA finds that: Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted and copy ot this report was given. No Citations were issued during this visit.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2