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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191603749
Report Date: 02/28/2024
Date Signed: 09/25/2024 03:46:29 PM

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
01/08/2024 and conducted by Evaluator David Espana
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240108103114
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: 111DATE:
02/28/2024
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Administrator Stephanie BrownTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are not addressing scabies at the facility.
INVESTIGATION FINDINGS:
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**The purpose of this amendment is to provide clarification of report delivered 02/28/2024, it does not change report findings.** On 02/28/2024 at 9:00 am Licensing Program Analyst (LPA) David España conducted a subsequent complaint continuation 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. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections.

The investigation consisted of the following: On 01/24/2024 at 2:09 pm LPA España conducted a tour of facility plant; reviewed records for staff, clients, client roster, staff roster, and made facility observations. LPA España conducted interviews 9 clients (C1-C9) on 01/11/2024. LPA España interviewed 6 staff (S1-S6) on 01/11/2024. On 2/16/2024 LPA Espana requested medication administration record for client 5 (C5). Continued LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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 6
Control Number 11-AS-20240108103114
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: 02/28/2024
NARRATIVE
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Investigation revealed the following:

Allegation: Staff are not addressing scabies at the facility
On 01/24/2024 LPA España conducted interviews with staff 1-staff 6 (S1-S6). Of those interviewed, 5 out of 6 stated that to their knowledge, none of the facility clients had scabies. On 01/24/2024 LPA España conducted interviews Client 1-Client 9 (C1-C9) regarding the allegation. Of those interviewed, 8 out of 9 clients disagreed with the allegation. During LPA’s interview with Client 5 (C5) it was reported that C5 had scabies. On 01/24/2024 LPA reviewed Providence St. Johns Health Center Emergency Department discharge summary dated 12/27/2023 that confirmed scabies diagnosis for C5, document was not provided to facility staff prior to complaint investigation. A follow-up interview was conducted with administrator Stephanie Brown who stated she was not provided with diagnosis or documentation by C5 previously, but would be taking appropriate infection control protocols now that they knew of the scabies diagnosis.

Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations 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 allegations is unsubstantiated.
Exit interview was conducted with facility representative as well as report was provided to Administrator Stephanie Brown.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20240108103114
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: 02/28/2024
NARRATIVE
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This page was intentionally left blank
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20240108103114
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: 02/28/2024
NARRATIVE
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This page was intentionally left blank
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20240108103114
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: 02/28/2024
NARRATIVE
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This page was intentionally left blank
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20240108103114
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: 02/28/2024
NARRATIVE
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This page was intentionally left blank
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6