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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 09/21/2022
Date Signed: 09/21/2022 05:00:04 PM

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
09/13/2022 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220913163734
FACILITY NAME:CROFTON MANOR INNFACILITY NUMBER:
191671691
ADMINISTRATOR:AMALIA ESQUIVIASFACILITY TYPE:
740
ADDRESS:1950 E. 5TH ST.TELEPHONE:
(562) 437-0093
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY:213CENSUS: 111DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Amalia EsquiviasTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident is being abused while in care
INVESTIGATION FINDINGS:
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On 9/21/2022, Licensing Program Analyst (LPA) Martessa Brown conducted a 10-day complaint visit at this facility regarding the allegation mentioned above. LPA Brown called the facility and conducted a risk assessment. LPA was met by Amailia Esquival, explained the purpose of today’s visit.

The investigation consisted of the following: LPA conducted interviews with the administrator Amailia Esquival, residents #1-8 and staff #1-4. LPA requested and obtained staff and resident roster, Physicians Reports, needs and service, emergency contacts and admission agreements. Also requested documents pertaining to the above allegation. A tour of the facility was conducted with the administrator.

Regarding: Resident is being abused while in care
.
LIC 9099 is on the next page.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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 2
Control Number 11-AS-20220913163734
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: 09/21/2022
NARRATIVE
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It was alleged that the resident is being abused and expressed suicidal ideas due to the living conditions in the facility. During today's investigation LPA conducted an interviews with the administrator. She stated there is no elder abuse at this facility and had no concerns. She stated the only recent incident was that R1's electricity was not working in the room and resident was very upset. She stated due to R1's medical history resident may get agitated and yells. She stated they are in communication with R1s doctors. LPA interviewed Resident R1, stated is being treated fine by staff and has not been abused while living in the facility and the living conditions are better. Interviews with R2-R8, stated staff treats them good and they have not or witnessed any physical abuse. Residents stated they feel safe in the facility. Interviews with staff #1-4, stated residents are treated good and there is no physical abuse and residents live in a safe and comfortable environment. Staff stated no residents had addressed any concerns to them. LPA observed resident during tour and did not observe any unsafe living conditions.

Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met. 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 allegation is Unsubstantiated.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2