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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602134
Report Date: 07/24/2025
Date Signed: 07/24/2025 04:10:06 PM

Document Has Been Signed on 07/24/2025 04:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 BEACHFACILITY NUMBER:
198602134
ADMINISTRATOR/
DIRECTOR:		MICHAEL MENDOZAFACILITY TYPE:
740
ADDRESS:1046 E 4TH STTELEPHONE:
(562) 432-7468
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY: 208CENSUS: 92DATE:
07/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Christopher Redmond (In-Training Executive Director)TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 07/24/2025 at 8:40am Licensing Program Analyst (LPA) Zina Brown and Lizeth Villegas and conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Catherine Dacara (Assistant Administrator) and explained the purpose of today’s visit. The facility is licensed to serve four (4) ambulatory, 174 non-ambulatory, and 30 bedridden resident age 60 and above. The facility is approved to accept or retain 30 residents on hospice and may accept or retain reside who have dementia. Currently, the facility has 92 residents. The facility has a current administrator certificate (#7019164740 Exp. 8/12/25) for Melissa Flores. The facility has liability insurance with Bridgeway Insurance Company with each occurrence at $1,000,000 and general aggregate at $3,000,000 (policy #8H-A7-MM-0002272 valid 12/05/2024 - 12/05/2025) The facilities annual fees are current.

The two-story commercial building consists of one hundred (100) resident bedrooms, multiple resident bathrooms,(3) common bathrooms, (4) shaded patios, (1) smoking area, dining room, commercial kitchen, staff room, office area, media room, garden area, a laundry, and multiple storage rooms. The facility has a memory care unit with delay egress doors.



LPA's Brown and Villegas conducted a records review of (10) resident records, (10) staff records, and the facility disaster plan. Facility disaster plan is observed to be current and in compliance with Title 22 regulations at the time of visit. LPA Brown conducted a review of (9) Resident Medication Administration Records did observe discrepancies at the time of visit.

Report continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/24/2025
NARRATIVE
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 Between the hours of 9:25am - 10:05am, LPA Villegas and staff toured the physical plant. Ten (10) bedrooms were inspected, (3) of the (7) bedrooms inspected were in the memory care unit. All bedrooms were observed to have pull cords located next to the residents bed and in the bathroom. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for residents’ personal belongings is available. In the memory care unit, the resident have auditory alarms located on outside patio doors. The water temperature was tested in (10) resident bathrooms. All rooms had the required furniture. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. LPA observed the facility to have a first aid kits, manual, and emergency supplies. A comfortable temperature was maintained in the facility.

LPA observed the facility to be sanitary, well maintained, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed and are accessible to residents. The commercial kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. LPA observed the kitchen area to be clean and free from pests. The facilities fire extinguishers were checked and found to be fully charged and accessible; and last serviced on 09/20/2023. All exit doors in the facility have alarm systems. The facility has hardwired and battery-operated smoke and carbon monoxide detectors and are in working condition. A working landline telephone remains available. The last fire drill was conducted 07/13/2025. There were no bodies of water or obstructions on the premises.

LPA observed the following not in compliance:
On 07/24/2025, LPA observed no personnel record on file for Staff #9 and medication discrepancies.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, and citations were issued at this time.

Exit interview was held and a copy of the Facility Evaluation Report with Appeal Rights were provided to Catherine Dacara (Assistant Administrator)

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2025 04:10 PM - It Cannot Be Edited


Created By: Zina Brown On 07/24/2025 at 02:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)(A-F)
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
(A) The name of the resident for whom prescribed.
(B) The name of the prescribing physician.
(C) The drug name, strength and quantity.
(D) The date filled.
(E) The prescription number and the name of the issuing pharmacy.
(F) Instructions, if any, regarding control and custody of the medication.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above for LPA observed 9 out of 9 resident MARs to indicate that medication was given but no signature. LPA also observed medication not administered but had signature indicated that it was administered, this poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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The licensee will have all staff who assist residents in care with medication administration to be re-trained by a licensed professional pharmacist. Proof of the training conducted to be submitted to the de[artment via email zina.brown@dss.ca.gov by POC due date and also the licensee to ensure medication audits are conducted regularly to avoid discrepencies.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Zina Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2025 04:10 PM - It Cannot Be Edited


Created By: Zina Brown On 07/24/2025 at 03:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and records review the licensee did not comply with the section cited above as staff #9 did not have a personnel record on file for LPA to review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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The licensee will personnel records such as the LIC 501, LIC 503 with TB Test results, LIC 508, First Aid/CPR certification for Staff #9 and submit proof to the department by via email at zina.brown@dss.ca.gov by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Zina Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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