<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 12/14/2022
Date Signed: 12/14/2022 11:39:20 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
12/07/2022 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20221207085239
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: 108DATE:
12/14/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:ADMINISTRATOR AMALIA ESQUIVASTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not treat resident with respect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility on 12/14/2022 at around 09:00 AM and was greeted by Administrator (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10 day visit on 12/14/2022 approximately around 09:00 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1). On 12/09/2022 LPA Calderon interviewed W1 for complaint. On 12/14/2022 LPA Calderon requested copies of the following: Staff and Resident rosters, physician report, needs and service plan for R1 and R2. On 12/14/2022 LPA Calderon interviewed S2-S4 for complaint. On 12/14/2022 LPA Calderon interviewed R2-R10 for complaint.
Regarding Allegation #1: Staff did not treat resident with respect.



Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
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-20221207085239
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: 12/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 12/09/2022 LPA Calderon interviewed W1 who states he has major issues with the administrator who has not helped W1 deal with another resident. On 12/14/2022 LPA Calderon interviewed S2-S4 who state to have knowledge of issues with R1 and R2, but no staff disrespects any resident and they have no issues with any resident. On 12/14/2022 LPA Calderon interviewed R2-R10 all state to have no issues with staff and all staff treat them with respect. On 12/14/2022 LPA Calderon reviewed needs and service plan and physician report for R1 and R2, neither residents suffer from any cognitive impairment or dementia or depression.
Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of Staff did not treat resident with respect is found to be UNSUBSTANTIATED.

An exit interview was conducted and copy of the Complaint Report was provided to the Administrator S1.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2