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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602134
Report Date: 01/23/2025
Date Signed: 01/23/2025 03:10:17 PM

Document Has Been Signed on 01/23/2025 03:10 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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: 99DATE:
01/23/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Administrator Melissa FloresTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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On 01/23/25 8:21 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced complaint investigation for control number 11-AS-20241003141025 at the facility listed above and met with Administrator Melissa Flores. LPA was following up on requested documents from 12/24/24 (email), 11/27/24 (email), 11/15/24 (visit), and 11/08/24 (visit). On 01/23/25 around 2:15 PM, partial documents were provided.

On 11/15/24, a technical violation was issued for CCR 87506 (a) Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

Deficiencies are being cited today under California Code of Regulations Title 22. See LIC809-D.

A copy of this report was discussed and a hard copy with the appeals was provided to the Administrator Melissa Flores.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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Document Has Been Signed on 01/23/2025 03:10 PM - It Cannot Be Edited


Created By: Regina Cloyd On 01/23/2025 at 02:37 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/28/2025
Section Cited
CCR
87506(a)

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87506 (a) Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidence by:
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The Licensee will provided controlled medication count records from April 2024 - November 2024 for Residents #1 - 5. The Licensee will also provide July 2024 - Oct 1, 2024 Medication Administration Records issued by former Executive Director (S1) by the POC due date.
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On 01/23/25 around 2:15 PM, LPA received partial records controlled medication count records for Residents #1 - 5 which poses a potential personal rights risk to residents in care. LPA did not receive medication administration records issued by the former Executive Director (S1).
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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