<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602134
Report Date: 12/16/2024
Date Signed: 12/16/2024 03:07:02 PM

Document Has Been Signed on 12/16/2024 03:07 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: DATE:
12/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:42 PM
MET WITH:Interim Administrator, Melissa FloresTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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
 On 12/16/24, Licensing Program Analyst (LPA) Felisa Shirley visited this facility to investigate a complaint and upon investigation learned that the medicine cabinet in R-9’s bathroom has rust on the inside and the cabinet is being used by the resident. The LPA met with Interim Administrator, Melissa Flores, and the purpose for the visit was discussed. LPA Shirley interviewed 9 staff members and 8 residents.


Deficiencies cited under California Code of Regulations Title 22

Exit Interview Conducted and a copy of this report was signed and left for, Interim Administrator, Melissa Flores.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/16/2024 03:07 PM - It Cannot Be Edited


Created By: Felisa Shirley On 12/16/2024 at 02:44 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: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2024
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Interim Administrator, Melissa Flores shall replace medicine cabinet and send proof of correction to LPA Felisa Shirley at felisa.shirley@dss.ca.gov or fax to 424-544-1016 by POC date of 12/30/24.

8
9
10
11
12
13
14
Based on interviews and observations, R-9’s bathroom medicine cabinet is rusted in the inside which poses a possible health and safety risk to persons in care.

8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2