191671691-4-19-2021-28-AS-MVAO-C3CRCS-20210525125448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 04/19/2021
Date Signed: 04/19/2021 07:31:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2019 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20191206103458

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:	DATE:	04/19/2021
		UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Amalia Esquivias		TIME COMPLETED:	01:27 PM

ALLEGATION(S):

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Facility staff failed to provide adequate supervision resulting in resident being hospitalized.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicol Wesley initiated a subsequent complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Amalia Esquivias and Assistant Administrator Francisca Vallejo arrived and joined the visit.

Investigation consisted of the following: LPA requested a copy of the staff roster, resident roster, and the schedule for the nocturnal shift staff. LPA Wesley reviewed the file for resident #1 and requested copies of specific documents. LPA Wesley interviewed the Administrator, Assistant Administrator, other parties, staff, and residents. LPA was not successful with interviewing Resident #1 as they were no Caregivers Supervisor, and staff. LPA made repeated attempts to interview resident #1 but was not successful.

Investigation revealed the following regarding allegation: Facility staff failed to provide adequate supervision resulting in resident being hospitalized. During the investigation with staff #1 LPA was informed that resident #1

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

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 28-AS-20191206103458

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 04/19/2021

NARRATIVE

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would always complain when staff would check on them at night. Staff also said resident #1 would tell them not to check on them as they are independent, doesn't need any help and by staff checking on them, made it hard for them to get back to sleep. Administrator Amalia Esquivias informed the LPA that the night staff conducts round checks every two hours and also provide incontinence care for residents who may require it. Administrator Esquivias said that there are a few residents who request for the staff to leave them alone during the night as they do not wish to be disturbed and resident #1 did not want to be checked on at night, so staff obeyed their wishes as they've complained that they can never go back to sleep when the staff comes to check on them. Staff #2 said on 11/28/19 resident #1 left the facility to join their close friend for a Thanksgiving celebration, and upon their arrival back to the facility during the night hours, they prepared for bed. On the morning of 11/29/19 at around 7:30 am staff #2 said they were completing their rounds to get the residents prepared to attend breakfast and noticed that resident #1 was not there as they see them every morning. Staff #2 knocked on resident #1's door, and when they entered into the room, they observed that resident #1 was on the floor. Resident #1 thanked staff #2 for coming and the staff observed that resident #1 had slurred speech, 911 was called and the resident was transported to the hospital. LPA interviewed a random selection of residents who said that the staff provided adequate supervision and it they require medical attention, they receive it in a timely manner. Assistant Administrator Francisca Vallejo was interviewed and said that resident #1 was one of the residents who complained about being disturbed during the night resident #1 and was not successful as they were not present in the facility.

Investigation revealed the following: Based on interviews conducted and observations made there was insufficient evidence to prove the allegation: "Facility staff failed to provide adequate supervision resulting in resident being hospitalized". Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. A telephonic exit interview was conducted with Administrator Amalia Esquivias, and a hard copy was provided via email to obtain signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

LIC9099 (FAS) - (06/04)

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