191671691-12-1-2021-11-AS-MCAA-C9NUWQ-20211213145707

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 12/01/2021
Date Signed: 12/01/2021 03:39:57 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/11/2021 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20211011152317

FACILITY NAME:	CROFTON MANOR INN		FACILITY NUMBER:	191671691
ADMINISTRATOR:	AMALIA ESQUIVIAS		FACILITY TYPE:	740
ADDRESS:	1950 E. 5TH ST.		TELEPHONE:	(562) 437-0093
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY:	213	CENSUS: 110	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	10:27 AM
MET WITH:	Amalia Esquivias		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff are chemically restraining residents.
Staff are not ensuring residents receive between-meal snacks and water.
Facility has bedbugs.
Facility does not provide planned activities for residents in care.

INVESTIGATION FINDINGS:

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On 12/01/21 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced subsequent visit,
Regarding the allegation(s) above. LPA was met by Facility Administrator Amalia Esquivias, and the purpose of the visit was explained.

The investigation consisted of the following: Physical Plant Tour, Interviews, and Record Review of Requested documents (Resident Roster, Staff Roster, Pest control Invoice).

Regarding Allegation: Staff are chemically restraining residents.
Interviews with caregiver staff and Administrator revealed that medications are only given by trained MedTech’s. Interviews with med tech revealed that no resident in care is being overmedicated for refusal of showers and is only given medication as prescribed. Interviews with Administrator revealed that the facility will not tolerate medications to be given to “chemically restrain” and has not received any complaints from any staff about over medicating. Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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-20211011152317

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 12/01/2021

NARRATIVE

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Interviews with Residents in memory care reveled that some take medications, some do not, and they are receiving their medications. No complaints were made to LPA that they were being Chemically Restrained by Medications. Therefore; Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding Allegation: Staff are not ensuring residents receive between meal snacks and water.
LPA observed in resident rooms in the secure memory ward all had blue jugs of water in each room.

LPA also observed white cups with lids with a liquid juice substance in the resident’s rooms. Interviews conducted with residents in care generally stated they do receive snacks and water. Interview with staff revealed that snack and water are provided in addition to meals. Based on Observation, and interviews conducted the LPA finds that; Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding Allegation: Facility has bedbugs.

The LPA along with the facilities Administrator took a physical tour of the facility, including inside the secured memory care resident rooms. The LPA did not observe any Pests/Bugs/Bedbugs. Administrator provided an invoice of the Pest Control Company’s (Orkin) findings. The secured memory care did not reflect any noted bedbugs, and facility administrator will continue to contract with pest control to ensure the facility is kept pest free. Interviews conducted with staff revealed that they have not witnessed any “Bed Bugs” in any of the rooms of Residents in Care, specifically the secured memory care ward. Based on Observation, Record Review, and Interviews, Conducted the LPA finds that; Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding Allegation: Facility does not provide planned activities for residents in care.

Interviews conducted with Activities Director indicated that there is a monthly calendar of activities posted in the activities room. Some activities include Music Relaxation, Puzzles, color matching, walks within the facility, and patio time.

Upon Entry of the Secured Memory Care Ward the LPA Observed 3 residents in care in the activities room utilizing color matching activity blocks.

Based on Observation, Record Review, and Interviews, Conducted the LPA finds that; Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

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