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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602620
Report Date: 06/27/2023
Date Signed: 06/27/2023 02:56:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
06/23/2023 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20230623102300
FACILITY NAME:LONG BEACH RESIDENTIALFACILITY NUMBER:
198602620
ADMINISTRATOR:CRYSTAL BARRIENTOSFACILITY TYPE:
735
ADDRESS:4201 EAST 10TH STREETTELEPHONE:
(562) 433-2455
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY:49CENSUS: DATE:
06/27/2023
UNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Crystal BarrientosTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Facility staff does not serve nutritious meals.
INVESTIGATION FINDINGS:
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On 6/27/23 Licensing Program Analyst (LPA) Felisa Shirley and Licensing Program Manager (LPM) Stephanie Cifuentes, conducted an unannounced complaint visit to the address listed above. LPA and LPM arrived at 10:13 and spoke to Administrator Crystal Barrientos and the purpose of the visit was discussed. LPA and LPM were granted access to the facility.

The investigation consisted of the following: On 6/27/23 LPA and LPM reviewed both Staff and Resident files and toured the kitchen. LPA and LPM reviewed and requested copies of the following records: Client Roster, Staff roster, weekly menus, admissions agreements, and staff training.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
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 3
Control Number 11-AS-20230623102300
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620
VISIT DATE: 06/27/2023
NARRATIVE
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The investigation revealed the following:
Allegation: Facility staff does not serve nutritious meals
On 6/27/2023 at 11:30am LPA Shirley reviewed facility files. During file review, LPA found that S4’s file does not contain any information on nutrition training. In reviewing the weekly menu, LPA found meal selections were not meeting the requirement of 1/3 of the servings recommended in the USDA Basic Food Group Plan.
On 6/27/23 from 12:07pm to 12:40pm LPA Shirley interviewed client 1 – client 6 (C1-C6). LPA asked if they enjoyed the food by the facility and all six clients interviewed stated they generally enjoyed the food. LPA asked residents if the facility served nutritious meals. Based on interviews, 5 out of the 6 felt that the meals provided were nutritious. On 6/27/23 from 12:07pm to 12:40pm LPA Shirley interviewed staff 1-staff 3(S1-S3). LPA asked staff if the meals served by the facility were nutritious. Of those interviewed, 2 out of 3 staff felt that the meals could be more nutritious.

Based on information gathered, the department did find sufficient evidence to support allegations " Facility staff does not serve nutritious meals.”

Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to Administrator Crystal Barrientos.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230623102300
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2023
Section Cited
HSC
80076(a)(1)
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Food Services
In facilities providing meals to clients, the following shall apply: All food shall be safe...Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan…
This requirement is not met as evidenced by:
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Administrator will review current weekly food menus and update selections according to the USDA Basic Food Group Plan. Please submit plan of correction to LPA’s Attn by fax or email by POC due date.
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During records review, LPA Shirley found that facility weekly menus provided for June 2023 did not meet the requirement of 1/3 servings recommended in the USDA Basic Food Group Plan on at least 3 days. This is a potential health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3