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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602134
Report Date: 11/06/2024
Date Signed: 11/06/2024 04:53:22 PM

Document Has Been Signed on 11/06/2024 04:53 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: 95DATE:
11/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Jonathan BarriosTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 11/06/24, the department made an unannounced visit to the facility listed above for an unrelated complaint. The department met with Co-Executive Director Jonathan Barrios, and the purpose of today’s visit was explained.

During today’s visit the department reviewed the Staff Roster (LIC500) and the Guardian Employee Roster, that indicates Staff S1 is “not eligible-exemption denial.” During the time of the visit, this was brought to the attention of the Co-Executive Director, and staff departed the facility and was taken off the schedule.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. CIVIL PENALTY ASSESSED.

An exit interview was conducted with Co-Executive Director, Jonathan Barrios and Gloriella Jara, and a copy of this report and Appeals Rights were provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 11/06/2024 04:53 PM - It Cannot Be Edited


Created By: Wendy Gibbs On 11/06/2024 at 01:23 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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
Section Cited
CCR
87356(a)(2)(3)

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87356 Criminal Record Exemption(a)The Department shall notify a licensee to act immediately to terminate the employment of, remove from the facility or bar from entering the facility any person described in Sections 87356(a)(1) through (5) below while the Department considers granting or denying an exemption. Upon notification, the licensee shall comply with the notice. (2) Any person who has been convicted of a felony;(3) Any person who has been convicted of an offense specified in Sections 243.4, 273a, 273d, 273g, or 368 of the Penal Code or any other crime specified in Health and Safety Code Section 1569.17(c)(3);
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Administrator shall read Section 87356(a)(1) through (5) and shall self-certify understanding of the regulations and shall commit to comply. POC shall be submitted to CCLD via email to wendy.gibbs@dss.ca.gov by the POC due date.
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This was not met based on observation, record review, and interview, the licensee failed to ensure S1 is fingerprint cleared prior to working in the facility. This poses a health, saftey, and/or persoanl rights 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.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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