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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602620
Report Date: 09/23/2022
Date Signed: 10/27/2022 12:34:05 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
09/12/2022 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20220912084945
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: 46DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:ADMINISTRATOR CRYSTAL BARRIENTOSTIME COMPLETED:
11:23 AM
ALLEGATION(S):
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Facility has pests
INVESTIGATION FINDINGS:
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THIS IS AN AMENDED REPORT TO CORRECT THE PAGES OF THE LICENSING REPORT DATED 9/19/22.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Long Beach Residential Facility on 09/19/2022 at around 09:00 AM and was greeted by Administrator (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
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 6
Control Number 11-AS-20220912084945
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: 09/23/2022
NARRATIVE
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10 day visit on 09/19/2022 approximately around 09:00 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1). On 09/16/2022 LPA Calderon interviewed W1 for complaint. On 09/19/2022 LPA Calderon requested copies of the following: Staff and Resident rosters, Maintained records for washers and dryers, pest control reports for prior 3 months and pharmacy records for W1. On 09/19/2022 LPA Calderon interview R2-R6 for complaint. On 09/19/2022 LPA Calderon interviewed S1 for complaint.

The investigation revealed the following:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20220912084945
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: 09/23/2022
NARRATIVE
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Regarding Allegation #1: Facility has pests: On 09/16/2022 LPA Calderon interviewed W1 who states the facility has bed bugs, roaches, lice in the building and W1 room. W1 states that W1 has complained to staff and nothing was done. On 09/19/2022 LPA Calderon interviewed S1 who states that S1 knew of issues with bed bugs in room 10 and did not know of any issues with bed bugs, roaches and lice in the building. On 09/19/2022 LPA Calderon interviewed R2-R6 all state major issues with bed bugs, roaches and lice in the building and that they have complained to staff and nothing has been done. LPA Calderon also spoke to other residents who also state major issues with bed bugs. On 09/19/2022 LPA Calderon reviewed pest control records for past 3 months all reports suggest spraying for bed bugs, roaches in many resident’s room.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of Facility has pest is found to be SUBSTANTIATED.

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to S1 by hand.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20220912084945
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: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2022
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds:A:The facility shall be clean, safe, sanitary:1:The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by:
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Administrator will engage the services of a pest control company and implement a plan that addresses eradicating bed bugs, roaches, and ants by treating the entire facility. Administrator will provide a written plan of action addressing sanitary conditions in client rooms and restrooms Pest control contract and written action plan will be faxed to CCL by 9/30/2022.
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Based on observation during facility tour and client interviews, LPA found the following: in rooms #3, #10 and #20 bedbugs and roaches observed on mattresses as well as floors, mildew in restrooms, in rm. #10 toilet was not clean and sanitary, ants and loose trash in the common area around trash reciprocal. During client interviews conducted 10 out of 10 clients stated bedbugs and roaches are present in various areas of the facility. This poses a potential health & safety risk to residents 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: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
09/12/2022 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20220912084945

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: 46DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:ADMINISTRATOR CRYSTAL BARRIENTOSTIME COMPLETED:
11:23 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility dryers are in disrepair
Staff are mismanaging residents medicationFacility dryers are in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
THIS IS AN AMENDED REPORT TO CORRECT THE PAGES OF THE LICENSING REPORT DATED 9/19/22.
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Long Beach Residential Facility on 09/19/2022 at around 09:00 AM and was greeted by Administrator (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10 day visit on 09/19/2022 approximately around 09:00 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1). On 09/16/2022 LPA Calderon interviewed W1 for complaint. On 09/19/2022 LPA Calderon requested copies of the following: Staff and Resident rosters, Maintained records for washers and dryers, pest control reports for prior 3 months and pharmacy records for W1. On 09/19/2022 LPA Calderon interview R2-R6 for complaint. On 09/19/2022 LPA Calderon interviewed S1 for complaint.
The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20220912084945
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: LONG BEACH RESIDENTIAL
FACILITY NUMBER: 198602620
VISIT DATE: 09/23/2022
NARRATIVE
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Regarding Allegation #1: Facility dryers are in disrepair. On 09/16/2022 LPA Calderon interviewed W1 who states the washers and dryers in the facility have not been working for 2 weeks. W1 states that he waited until the washers and dryers were fixed to clean his clothes. On 09/19/2022 LPA Calderon interviewed S1 who states that the facility washers and dryers stopped working on 09/05/2022, S1 put in a work order which was taken care of by technician on 09/09/2022. On 09/19/2022 LPA Calderon interviewed R2-R6 all resident state that washer and dryers were not working for 2 or 3 days and staff had them repaired. No resident stated to be out of pocket any money for cleaning clothes. On 09/19/2022 LPA Calderon received, and reviewed work order dated 09/05/2022 and taken care of on 09/09/2022. Records support that washer and dryers were not working for 4 days.

Regarding Allegation #2: Staff are mismanaging residents’ medication. On 09/16/2022 LPA Calderon interviewed W1 who states that staff gives W1 used or empty inhalers on a regular basis and W1 has complained to staff with nothing being done. On 09/19/2022 LPA Calderon interviewed S1 who states that W1 inhalers are ordered through pharmacy on a monthly basis and no used or empty inhalers are given to W1. S1 states that all W1 medication are ordered through pharmacy and there is not possible to give used medication to any resident. On 09/19/2022 LPA Calderon interviewed R2-R6 who all state to have no issues with their medication and staff gives them their medication on time and in the correct amount. On 09/19/2022 LPA Calderon received and reviewed pharmacy records for W1 medications including inhalers which are new when given to W1.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of Staff conduct unreasonable searches, Facility dryers are in disrepair, Staff are mismanaging residents’ medication is found to be UNSUBSTANTIATED.



An exit interview was conducted and copy of the Complaint Report was provided to the Administrator (S1).
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6