191603749-11-15-2024-11-AS-SCIS-DC53A7-20241219170417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191603749
Report Date: 03/27/2024
Date Signed: 11/15/2024 10:11:02 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
and conducted by Evaluator David Espana

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240319092522

FACILITY NAME:	MANOR, THE		FACILITY NUMBER:	191603749
ADMINISTRATOR:	STEPHANIE BROWN		FACILITY TYPE:	735
ADDRESS:	1905/2019 PICO BOULEVARD		TELEPHONE:	(310) 450-1748
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90405
CAPACITY:	151	CENSUS: 109	DATE:	03/27/2024
		UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Assistant Administrator Terry Santos		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff financially abused resident in care.

INVESTIGATION FINDINGS:

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** This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 03/27/2024.** On 03/27/2024 at 9:00 am Licensing Program Analyst (LPA) David España conducted a complaint investigation visit for the allegation listed above to deliver findings. Upon arriving at the facility, LPA met with Stephanie Brown, Administrator who assisted with the visit. The purpose of today’s visit was discussed. LPA was granted access.

THE INVESTIGATION CONSISTED OF THE FOLLOWING:
On 03/27/2024 LPA España conducted a tour of facility plant and conducted interviews with clients #1-client #5 (C#1-C#5) and staff #1 – staff #6 (S#1-S#6). LPA reviewed records for staff, clients, client roster, staff roster, and made facility observations. Additionally, reviewed records Personal Rights; Emergency Intervention Documentation and Reporting Requirements; Admission Agreements.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Benita Yates
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240319092522

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MANOR, THE	FACILITY NUMBER: 191603749
	VISIT DATE: 03/27/2024

NARRATIVE

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Admission Procedures; Modifications to Needs and Services Plan. Continued LIC 9099-C; Needs and Services Plan; Continuing Education Training Program Course Approval Requirements; Medical Examination; Observation of the Client; Eviction Procedures; Continuing Education Training Program; Vendor Requirements; Hospice Care; Initial Certification Training Program Vendor and Program Approval Requirements; Administrator Certification Requirements.

THE INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff financially abused resident in care.
On 03/27/2024 LPA España interviewed client 1 – Client 5 (C1-C5). Of those interviewed, 5 out of 5 clients denied any incidents of financial abuse, stating that they had not experienced or witnessed any such behavior while in the facility. On 03/27/2024 LPA España interviewed 6 staff members. Of those interviewed, 6 out of 6 staff members reported no knowledge or evidence of financial abuse occurring within the facility. On 03/27/2024 LPA España conducted a review of facility files, of those reviewed was the discharge forms for client (C6) which showed that C6 voluntarily left the facility on April 8, 2022. LPA España reviewed the files of clients C#1 - C#5 and saw no discrepancies.

Continued on 9099-C.

SUPERVISORS NAME: Benita Yates
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240319092522

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MANOR, THE	FACILITY NUMBER: 191603749
	VISIT DATE: 03/27/2024

NARRATIVE

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Based on interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted, and a copy of the report was given to Administrator Stephanie Brown

SUPERVISORS NAME: Benita Yates
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

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