191671691-12-6-2022-11-AS-MVAO-CMC23C-20221221160206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 12/05/2022
Date Signed: 12/06/2022 08:02:22 AM

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
11/29/2022 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20221129121556

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: 108	DATE:	12/05/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	AMALIA ESQUIVIAS		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff are not adequately supervising residents while in care.

INVESTIGATION FINDINGS:

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On 12/5/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a 10-day complaint visit at this facility. LPA Montoya called and conducted a risk assessment with Administrator Amalia Esquivias (S1) who confirmed the facility has positive Covid-19 case. LPA met with Administrator Esquivias (S1) and explained the purpose of the visit.

The investigation consisted of the following: LPA Lourdes Montoya toured the facility with S1. LPA requested and obtained copies of two residents’ (R1 and R2) service records: Admission Agreement, Physician’s Report and Appraisal. LPA attempted to interview R1 but R1 was not in the facility during the visit. LPA interviewed six staff (S1-S6) and twelve residents (R2-R13). LPA interviewed one witness (W1) and made an unsuccessful attempt to interview another potential witness (W2).

REPORT CONTINUED IN LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

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-20221129121556

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: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 12/05/2022

NARRATIVE

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INVESTIGATIONS REVEALED:

ALLEGATION: Facility staff are not adequately supervising residents while in care.

It is alleged Facility staff are not adequately supervising residents while in care. Reporting Party (RP) reported Resident #1 (R1) is being stalked and harassed by Resident #2 (R2). RP stated R1 has notified the facility staff but they do not assist R1. Based on LPA’s records review and interview with a staff (S1), both residents (R1 and R2) are independent and do not necessarily need close supervision. S1 stated nevertheless, staff frequently check on them to ensure their safety. S1 stated R1 and R2 used to be close friends and are now encountering conflicts. S1 added she had contacts with R1 and R2 as well as R1's family and friend and continuing to offer resolution to the situation between R1 and R2. Interview with a witness (W1) revealed R1 is independent but she witnessed staff checks on her frequently; staff bring meals to R1’s room and staff always provide care to R1. During interview with six staff (S1-S6) and twelve residents (R2-R13), it was revealed that staff are adequately supervising residents in care. Based on LPA’s interviews, observations and records review, there is no sufficient evidence to corroborate the above allegation.

Although the allegation 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 above allegation is Unsubstantiated

An exit interview was conducted with Administrator Amalia Esquivias, and a hard copy of the report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022

LIC9099 (FAS) - (06/04)

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