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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 04:23:28 PM

Substantiated


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:
09:57 AM
MET WITH:Stephanie Brown - AdministratorTIME COMPLETED:
04:43 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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On 5/16/2023, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced complaint visit at this facility to obtain additional information related to the above allegations. LPA was greeted by assistant-Administrator (S2). Administrator (S1) arrived later and joined the visit. LPA explained the purpose of the visit.

The investigation consisted of the following: On 5/16/2023, LPA conducted an initial investigation. LPA obtained copies of the facility roster for residents and staff and house rules for the facility along with blank admissions agreement. Interviews were conducted with four staff (S1-S4) and nine residents (R1-R9). LPA was unable to obtain information from one resident (R10) due R10’s denial of interview. A tour of the facility was conducted with S1, during which LPA conducted observations in ten (10) out of thirty-one (31) bathrooms .
On 09/05/23 and 10/09/23 LPA took tours of the facility to further observe and obtain additional interview information.
Report continued in LIC 9099C
Substantiated
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 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
CCR
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Type B
06/02/2023
Section Cited
CCR
80087(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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LPA and Administrator (S1) have agreed that S1 will provide a plan of corrections for the ceiling directly outside of Room 22 and the main office. In addition, the glass window in room 11C and the front door glass will be repaired as well as any broken screens, loose and or broken electrical outlets, not
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Based on LPA observation and interviews conducted (R1-R9) and (S1-S4), the facility failed to ensure clients remain to be kept in a safe environment.

which poses a potential health, safety or personal rights risk to persons in care.
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limited to rooms #31.
Corrections will be submitted, via email, to Mario.Leon@dss.ca.gov
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: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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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The investigation revealed the following:

Regarding the allegation: the facility is in disrepair. On 5/16/23 LPA interviewed nine (9), out of ten (10) residents (R1-R9) and four (4) staff (S1-S4). All four (4) staff agree that the facility is unsafe, while four (4) clients agree the facility needs repair.
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). Six (6) out of Ten (10) residents agree with the allegation and three (3) out of four (4) staff have agreed with the allegation.

LPA's record review showed that on 05/11/23 Los Angeles Dept. of Public Health had conducted an inspection that mentioned of a caved roof outside of unit #22. The report also informed of the Southwest wall of the building being in disrepair and needing to be addressed and that window sills were in disrepair.
LPA observed the landing of the third (3rd) floor from outside unit #22, which showed water damage with potential for future injuries. LPA observed the landings of the 2nd and 3rd floors currently being repaired. LPA observed the Southwest wall's painting needing to be replaced. LPA observed Southeast wall's window sills needing to be repaired and/or replacement in four (4) out of ten (10) window sills observed.

According to LPA's observations, interviews and record review conducted, there is enough evidence to support the above allegation. Therefore the above allegation is Substantiated.

Exit interview conducted, and a copy of the report and appeal rights were provided to Stephanie Brown, Administrator.
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: 3 of 3