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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602134
Report Date: 01/13/2025
Date Signed: 01/13/2025 02:59:29 PM

Document Has Been Signed on 01/13/2025 02:59 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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: 97DATE:
01/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:44 PM
MET WITH:Melissa FloresTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 01/13/25, the department conducted an unannounced visit to this facility. The department met with Quality Assurance Director, Melissa Flores, and the purpose of the visit was explained.

This visit was conducted to amend the citation issued on 01/06/25 and to issue a civil penalty in association with complaint investigation # 11-AS-20241115103623.

Civil penalties are being assessed, see LIC421IM.

An exit interview was conducted and a copy of this report, amended deficiency notice, LIC421IM, and appeal rights were discussed and left with Quality Assurance Director, Melissa Flores.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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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