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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602134
Report Date: 11/14/2024
Date Signed: 11/15/2024 11:07:09 AM

Document Has Been Signed on 11/15/2024 11:07 AM - 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:
11/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Gloriella JaraTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Case Management Visit on Thursday, November 14, 2024, upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a risk assessment. Based on the assessment, the facility is cleared of COVID-19 infection.

LPA Bunker met with Co-Executive Director Gloriella Jara and explained the purpose of today's visit is to amend the complaint report received in the Community Care Licensing office on April 19, 2024, Control #11-AS-20240419102426.

The original complaint report, dated Thursday, November 7, 2024, has been amended, and corrections were made on the LIC9099, LIC9099-Cs, LIC9099-D, and LIC9099-A. This amended complaint report, dated Thursday, November 14, 2024, supersedes the original complaint report dated Thursday, November 7, 2024.

There were no deficiencies cited.

An exit interview was conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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