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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602620
Report Date: 03/10/2023
Date Signed: 03/10/2023 03:00:54 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
03/06/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230306103507
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: 47DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:ADMINISTRATOR CRYSTAL BARRIENTOSTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has an infestation of bed bugs
Facility is in disrepair
Staff failed to meet resident's medical needs
Staff failed to administer resident's medication as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
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12
13
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Long Beach Residential Facility on 03/10/2023 at around 08:30 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 03/10/2023 approximately around 08:30 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1). On 03/06/2023 LPA Calderon interviewed W1 for complaint. On 03/10/2023 LPA Calderon requested copies of the following: Staff and Resident rosters, admission agreement, Needs and Service Plan, Physician Report, MAR for W1, pest control records for 3 prior months. On 03/10/2023 LPA Calderon interview R1-R5 for complaint. On 03/10/2023 LPA Calderon interviewed S2–S3 for complaint. On 03/10/2023 LPA Calderon interviewed W2 for complaint.
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
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 8
Control Number 11-AS-20230306103507
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: 03/10/2023
NARRATIVE
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Regarding Allegation #1: Facility has an infestation of bed bugs

On 03/06/2023 LPA Calderon interviewed W1 for complaint. W1 states that W1 has seen bed bugs in the facility and has seen pest control spraying for bugs. On 03/10/2023 LPA Calderon interviewed S1-S3 who state that they have no knowledge of any bed bugs in the facility, but state that pest control does spray for bugs. On 03/10/2023 LPA Calderon interviewed R1-R5 for complaint. Resident’s state there are bed bugs in the past but have not see any bugs in their rooms. On 03/10/2023 LPA Calderon reviewed 3 months of pest control records. Pest control records support bed bugs in many rooms and spraying was done. On 03/10/2023 LPA Calderon interviewed W2 for complaint. Pest control staff states that if they sprayed for bed bugs there was active signs of bed bugs in the rooms sprayed.

Regarding Allegation #2: Facility is in disrepair.

On 03/06/2023 LPA Calderon interviewed W1 for complaint. W1 states that the facility needs work, staff do not take care of the facility needs. W1 states room 8 upper windows do not work. On 03/10/2023 LPA Calderon toured the facility with S1. LPA noted bathroom 1 water leak in the ceiling, dry wall was damaged. Bathroom 2 water pipe busted and bathroom leaking. Bathroom 3 toilet did not have a lid. Room 8 upper window does not work, and no window screen was found. On 03/10/2023 LPA Calderon interviewed S1-S2 who state that staff works hard to keep facility running and some items need repair, and they do the best possible. On 03/10/2023

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 11-AS-20230306103507
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: 03/10/2023
NARRATIVE
1
2
3
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5
6
7
8
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10
11
12
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Regarding Allegation #3: Staff failed to meet residents’ medical needs.

On 03/06/2023 LPA Calderon interviewed W1 for complaint. W1 states that staff failed to meet W1 medical needs and failed to give W1 medication on time. On 03/10/2023 LPA Calderon interviewed S1-S2 who state that W1 did not follow up with them regarding insulin shots and failed to advise staff that insulin needed to be kept cool. S1-S2 state that they did not follow up in writing with W1 doctor for the type of insulin that would be needed for resident’s care.

Regarding Allegation #4: Staff failed to administer residents’ medication as prescribed.

On 03/06/2023 LPA Calderon interviewed W1 for complaint. W1 states that staff failed to give W1 insulin shot on time or to follow up with W1 or W1 doctor. On 03/10/2023 LPA Calderon interviewed S1-S2 for complaint. Staff states that they did not follow up on W1 type of insulin shot needed for W1 care and did not follow up with W1 medical paperwork to make sure W1 medical need would be met. On 03/10/2023 LPA Calderon noted there was no current physician report or needs and service plan for W1 medical care. LPA Calderon did note prior physician report from prior facility. Report states that W1 is diabetic and would need insulin shots taken for W1 care.

Based on LPA Calderon observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegations “facility has an infestation of bed bugs” “facility is in disrepair” “staff failed to meet residents’ medical needs” “staff failed to administer residents’ medication as prescribed” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are being cited on the attached LIC 9099D.

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator (S1).

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20230306103507
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: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2023
Section Cited
CCR
80087(a)(1)
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4
5
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7
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:
1
2
3
4
5
6
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Administrator will engage the services of a pest control company and implement a plan that addresses eradicating bed bugs 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 3/14/2023.
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Based on observation during facility tour and client interviews, LPA noted that the pest control report supports bed bugs in the facility. This poses a potential health & safety risk to residents in care.

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Type B
03/14/2023
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
1
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Administrator will have staff repair all bathroom issues and residents window damage. Administrator will given written report to LPA Calderon by email by 03/14/2023
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Based on observation during facility tour and client interviews, LPA bathroom 1 had a water leak and the ceiling drywall was damaged.. Bathroom 2 toilet lid was missing. Bathroom 3 sink pipe was bbroken and flooded the floor. Room 8 window did not work. 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: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20230306103507
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: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2023
Section Cited
CCR
80075(b)
1
2
3
4
5
6
7
80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.This requirement is not met as evidenced by:
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Administrator will follow up with doctor and resident regading resident medical needs and report to LPA by 03/14/2023
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Based on observation during facility tour and client interviews, LPA did not see or obtain physician report. LPA interview of staff noted that no follow up was done with resident doctor regarding residents medical needs.This poses a potential health & safety risk to residents in care.
8
9
10
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14
Type A
03/14/2023
Section Cited
CCR
80075(b)
1
2
3
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5
6
7
80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will follow up with doctor and resident regading resident medical needs and report to LPA by 03/14/2023
8
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Based on observation during facility tour and client interviews, LPA did not see or obtain physician report. LPA interview of staff noted that no follow up was done with resident doctor regarding residents medical needs.This poses a potential health & safety risk to residents in care.
8
9
10
11
12
13
14
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: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
03/06/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230306103507

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: 47DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:ADMINISTRATOR CRYSTAL BARRIENTOSTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has an outbreak of head lice
Staff threatened resident
Staff failed to ensure a supply of basic hygiene products are available for residents in care
Staff failed to keep the facility clean
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
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13
This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 03/10/2023

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Long Beach Residential Facility on 03/10/2023 at around 08:30 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.


The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20230306103507
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: 03/10/2023
NARRATIVE
1
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3
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5
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10-day visit on 03/10/2023 approximately around 08:30 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1). On 03/06/2023 LPA Calderon interviewed W1 for complaint. On 03/10/2023 LPA Calderon requested copies of the following: Staff and Resident rosters, admission agreement, Needs and Service Plan, Physician Report, MAR for W1, pest control records for 3 prior months. On 03/10/2023 LPA Calderon interview R1-R5 for complaint. On 03/10/2023 LPA Calderon interviewed S2–S3 for complaint. On 03/10/2023 LPA Calderon interviewed W2 for complaint.

Regarding Allegation #1: Faculty has outbreak of head lice.

On 03/06/2023 LPA Calderon interviewed W1 for complaint. W1 states that there is a outbreak of head lice in the facility. W1 states that W1 does not know the name of the resident that has lice. On 03/10/2023 LPA Calderon interviewed S1-S2 who state there is no outbreak of head lice, and state resident in room 4 did have lice in the past and staff treated resident with medication and the situation was resolved. On 03/10/2023 LPA Calderon interviewed R1-R5 who all states to have no information of any outbreak of head lice and have never had lice in their hair.

Regarding Allegation #2: Staff threatened resident.

On 03/06/2023 LPA Calderon interviewed W1 for complaint. W1 states that S2 threatened W1 due to making a complaint regarding W1 medical care. On 03/10/2023 LPA Calderon interviewed S1-S2 who state that no staff would threaten any resident for any reason. S1 states that if a staff member attacked or threatened residents that staff member would be fired. On 03/10/2023 LPA Calderon interviewed S2 for complaint. S2 states that S2 has never had words with residents. S2 states that S2 works with all residents and would never threaten any resident and residents have the right to make a complaint. On 03/10/2023 LPA Calderon interviewed R1-R5 for complaint. Residents state that they feel safe in the facility and no staff has ever attacked or threatened any resident at any time. Residents work with S2 every day and have no issues with S2 service and have never had words with S2.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20230306103507
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: 03/10/2023
NARRATIVE
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Regarding Allegation #3: Staff failed to ensure a supply of basic hygiene products are available for residents in care.

On 03/06/2023 LPA Calderon interviewed W1 for complaint. W1 states that the facility does not supply any hygiene products to the residents and W1 must purchase the supplies. On 03/10/2023 LPA Calderon interviewed S1-S3 who state that facility purchases hygiene supplies weekly and makes sure residents have what they need. On 03/10/2023 LPA Calderon interviewed R1-R5 who all state that the facility supplies all the hygiene they need weekly. Residents state that if they need cleaning supplies they just need to ask, and supplies are given to them. On 03/10/2023 LPA Calderon toured the facility. LPA noted hygiene supplies in bathroom 1,2 and 3, soap in the shower and toilet paper in each bathroom.

Regarding Allegation #4: Staff failed to keep the facility clean.

On 03/06/2023 LPA Calderon interviewed W1 for complaint. W1 states that staff due not clean the facility and the building has trash all over the grounds and is not clean. On 03/10/2023 LPA Calderon interviewed S3 who states that S3 and 2 other staff clean the facility daily and there is an issue of trash, or something needs to be cleaned all residents must do is tell staff and cleaning is done. On 03/10/2023 LPA Calderon interviewed S1 for complaint. S1 states that there are 3 cleaning staff that work AM and PM shifts. S1 states that staff cleans the facility every day and any issues from residents regarding cleaning is addressed on the same day. On 03/10/2023 LPA Calderon toured the facility and noted S3 was cleaning the facility. All trash was picked up and mopping was being done. Inspected lower and upper bathrooms and common areas. All areas were clean and no trash was found.


Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of “facility has an outbreak of head lice” “staff threatened resident” “staff failed to ensure a supply of basic hygiene products are available for residents in care” “staff failed to keep the facility clean” 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: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8