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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191220311
Report Date: 02/08/2022
Date Signed: 02/08/2022 02:25:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/01/2019 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20190701161517
FACILITY NAME:MANILA MANOR IIFACILITY NUMBER:
191220311
ADMINISTRATOR:JAZMIN R. GAITEFACILITY TYPE:
740
ADDRESS:17740 BALTAR STREETTELEPHONE:
(818) 342-8738
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:0CENSUS: 5DATE:
02/08/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Vicky Paredes, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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The Administrator fails to provide sufficient hours to permit adequate attention to the management and administration of the facility.
INVESTIGATION FINDINGS:
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At 1:15pm Licensing Program Analyst (LPA) Angela Panushkina responded to the facility for a subsequent complaint visit to deliver the finding for the allegation listed above. LPA met with Staff #1 who granted access to home. LPA spoke with previouse Administrator (Jazmine Gaite) over the phone and explained the reason for the visit.

On 07-05-2019 the department initiated the complaint. Interviews were conducted with staff and documentation was reviewed.

Allegation: The Administrator fails to provide sufficient hours to permit adequate attention to the management and administration of the facility.

LPA conducted a file review and found that the Administrator Jazmine Gaite is managing 3 facilities Manila Manor I, II, and III. Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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 3
Control Number 31-AS-20190701161517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MANILA MANOR II
FACILITY NUMBER: 191220311
VISIT DATE: 02/08/2022
NARRATIVE
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On 07-09-2021 the department initiated a complaint. A tour, interview and files were reviewed.
On 07-09-2019 LPA issued various deficiencies and a civil penalty for violations related and unrelated to this complaint. Deficiencies include, criminal record clearance staff not associated to the facility; reporting requirements resident eloped from the facility; failure to meet resident needs, Admissions agreement, failure to issue refund promptly; medications not stored in their original containers; no doctor’s orders for changes in medication administration; strong odor in the facility; kitchen cabinets dirty, failure to maintain appropriate temperature in the freezer, contaminated food, and potential tripping hazard with long extension cord that extended between the walk way of Manila Manor I and Manila Manor II. Therefore, after review, the allegation Administrator fails to provide sufficient hours to permit adequate attention to the management and administration of the facility is substantiate. Administrator did not permit adequate attention to manage staff and the operation of the facility to prevent deficiencies.

Deficiencies and appeal rights issued.

Exit interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20190701161517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MANILA MANOR II
FACILITY NUMBER: 191220311
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2022
Section Cited
CCR
87405(a)
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87405 Administrator - Qualifications and Duties. (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...

This requirement is not met as evidenced by:
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The Administrator agrees to provide sufficient hours to permit adequate attention to the management and administration of the facility. LIC500 will be emailed to LPA by POC date
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Based on documentation & observation the licensee didn’t comply with section cited above. The Admin. of 3 facilities didn't put in a sufficient number of hrs. to permit adeq uate attention to the mngmt & administration of the facility resulting in multiple deficiencies & compliance issues. This is an immediate health and 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3