<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602134
Report Date: 06/15/2026
Date Signed: 06/15/2026 10:33:17 AM

Document Has Been Signed on 06/15/2026 10:33 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:GLEN PARK AT LONG BEACHFACILITY NUMBER:
198602134
ADMINISTRATOR/
DIRECTOR:		ACE HUYNHFACILITY TYPE:
740
ADDRESS:1046 E 4TH STTELEPHONE:
(562) 432-7468
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY: 208CENSUS: 109DATE:
06/15/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:Ace Huynh & Anita CsukardiTIME VISIT/
INSPECTION COMPLETED:
10:59 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On June 15, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit to the facility following an incident reported by the facility that occurred on June 6, 2026. During the visit, the LPA met with Anita Csukardi & Ace Huynh, Executive Directors to explain the purpose of the inspection.

The El Segundo Regional Office Adult and Senior Care received an Unusual Incident Report (LIC 624) on June 8, 2026, stating that Resident #1 (R1) had been given the wrong medication. On June 6, 2026, at 4 PM, the medication technician mistakenly verified only (R1's) last name without confirming the correct resident. Consequently, (R1) was administered medications intended for another resident with the same last name. As a result, both Metformin and Senna were given to (R1) in error, leading to hospitalization in the emergency room.

The Department found that the facility was not in compliance with Title 22 Regulations and issued citations as follows:

87465(c)(2) Incidental Medical and Dental Care Services. The investigation revealed that the facility failed to comply with Title 22 regulations. The LPA reviewed (R1’s) Physicians Report (LIC 602A) (dated 07/27/23) and Medication List (dated 06/15/26), which confirmed that (R1) was not prescribed Metformin by (R1's) physician.

Based on interviews, observations, and record reviews, the licensee was found in violation of the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8.

Deficiencies have been issued, and an exit interview was conducted with Ace Huynh, Executive Director. A copy of this report is provided, along with the appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
Document Has Been Signed on 06/15/2026 10:33 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 06/15/2026 at 09:30 AM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GLEN PARK AT LONG BEACH
FACILITY NUMBER: 198602134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2026
Section Cited
CCR
87465)(c)(2)

1
2
3
4
5
6
7
87465)(c)(2) Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions.
1
2
3
4
5
6
7
Licensee shall provide medication administration in-service training to all staff that dispense medications. This training shall be provided by pharmacy and/or registered nurse. Submit proof of training by POC due.06/16/26.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on the records review, facility staff did not verify the medication record and administered medication Metform that was not prescribed to (R1). The facility reported a medication error: administering the wrong medications intended for another resident with the same last name. This violation poses/posed an immediate risk to persons in care.
8
9
10
11
12
13
14
Citation was cleared during the visit. Medication training took place on 06/10/26 with a registered nurse.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2026


LIC809 (FAS) - (06/04)
Page: 3 of 3