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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191603749
Report Date: 05/16/2023
Date Signed: 10/09/2023 04:19:55 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/09/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230509141225
FACILITY NAME:MANOR, THEFACILITY NUMBER:
191603749
ADMINISTRATOR:STEPHANIE BROWNFACILITY TYPE:
735
ADDRESS:1905/2019 PICO BOULEVARDTELEPHONE:
(310) 450-1748
CITY:SANTA MONICASTATE: CAZIP CODE:
90405
CAPACITY:151CENSUS: 96DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Stephanie Brown - AdministratorTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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9
Facility has mold.
Facility does not provide a safe environment for residents in care.
INVESTIGATION FINDINGS:
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On 10/09/23 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unannounced, complaint visit at this facility to re-deliver findings related to the above allegation which includes additional interviews conducted with ten (10) out of fifty-one (51) residents and five (5) out of twelve (25) staff. LPA was greeted by Teresita Santos, Assistant-Administrator (S2), and was later joined by Administrator, Stephanie Brown (S1) and LPA explained the purpose of the visit.

The investigation consisted of the following:
On 05/16/2023, LPA took a tour of the facility, inside and out, which was conducted with S1. LPA obtained copies of the facility roster for residents and staff and house rules for the facility as well as the blank admissions agreement. Interviews were conducted with four staff (S1-S4) and ten residents (R1-R10). LPA observed the bathrooms in ten (10) out of thirty-one (31) units.
On 09/05/2023, LPA took a tour of the facility, conducted with S1, to re-visit the unit that had been initially reported on as well as the unit located directly above it.
Report continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
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 2
Control Number 11-AS-20230509141225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MANOR, THE
FACILITY NUMBER: 191603749
VISIT DATE: 05/16/2023
NARRATIVE
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On 09/27/23 LPA further interviewed S1, via telephone, regarding the timeline related to the mold present in the facility.
On 10/09/23 LPA toured the facility, with S2, interviewed 10 out of 51 residents and 5 out of 25 staff.
The investigation revealed the following:
On 05/16/23 LPA toured facility with S1. During the tour, LPA interviewed S1. Stephanie Brown (S1) was notified of the mold in unit 10 on 04/10/23. LPA observed photo evidence of mold in unit 10 bathroom, dated 04/10/23. LPA further interviewed S1 on 09/27/23, where S1 informed LPA that the repair was completed on 04/12/23, but was not invoiced until 04/19/23. During LPA's record review, on 09/28/23, an invoice was produced via text message.
On 10/09/23 LPA interviewed ten (10), out of fifty-one (51) residents (R4-5, R7-9 & R11-15) and four (4) staff (S2-3, S5-6) regarding mold. Eight (8) out of ten (10) residents have denied the allegation and all four (4) staff deny the allegation.

On both 05/16/23 and 09/05/23 LPA observed there was no mold present in the unit that had been reported on.
According to LPA's observations, interviews and record review conducted, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is Unsubstatiated.

Regarding the allegation: Facility does not provide a safe environment for residents in care. It has been alleged that the trees are not trimmed for public to safely walk by. On 10/09/23 LPA interviewed ten (10), out of fifty-one (51) residents (R4-5, R7-9 & R11-15) and four (4) staff (S2-3, S5-6). Eight (8) out of Ten (10) residents have denied the allegation and four (4) out of four (4) staff have denied the allegation.
LPA observed the trees to be properly trimmed along the sidewalk and the overhang of trees properly trimmed along Pico Blvd.
According to LPA's observations, interviews and record review conducted, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is Unsubstatiated. An exit interview was conducted with Stephanie Brown (S1), and a copy of the report was provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2