191671691-4-28-2023-11-AS-EMAZ-CRJV5R-20230505160823

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 04/28/2023
Date Signed: 04/28/2023 03:17:30 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
04/14/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20230414082004

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: 118	DATE:	04/28/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	ADMINISTRATOR AMALIA ESQUIVAS		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is refusing to take resident back into care
Staff did not re-order resident's medication timely
Resident missed medications

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 04/28/2023 around 09:00 AM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation for Crofton Manor Inn to deliver the investigation findings for the allegation listed above. LPA met with Administrator Amalia Esquivas (A1) and the purpose of the visit was explained.

The investigation revealed the following:

During this investigation, LPA Calderon interviewed R1-R12, A1, S2-S3, W1. These interviews were conducted on 04/17/2023, 04/21/2023 and 04/28/2023. LPA Calderon obtained copies of Staff and Resident rosters, Needs and Service Plan, Pre-Placement Appraisal, Medication Administration Records (MARS), Physicians Report, admission agreement, Skilled Nursing Facility (SNF) reports for past and current SNF for R1.

Allegation 1: Facility is refusing to take resident back into care.

It is alleged that facility is refusing to take resident back into care. On 04/17/2023 LPA Calderon interviewed W1 for complaint. W1 states that R1 was moved to SNF, and facility would not allow R1 to come back to the facility. W1 states that A1 did not give W1 anything in writing as to why R1 would not be allowed to return to the facility. On 04/28/2023 LPA Calderon interviewed R1 for complaint. R1 states that R1 came from SNF due to breaking R1 left hip. R1 states that R1 was moved to detox hospital for unknown reason and then moved to SNF for unknown reason. R1 states that R1 does not know why R1 was taken to SNF and does not know why facility will not take R1 back to the facility. On 04/28/2023 LPA Calderon interviewed R2-R12 for complaint. R2, R6, R8, R10 and R12 state that they had to go to hospital or SNF and facility did not allow them to return right away. Residents state that they did return to the facility with no issues. R3, R4, R5, R7, R9, and R11 all state that the facility has never refused to allow them back into the hospital after making a trip to SNF or the hospital.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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 3

Control Number 11-AS-20230414082004

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: 04/28/2023

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 04/21/2023 LPA Calderon reviewed the SNF paperwork and noted that R1 will be discharged from their facility as of 05/06/2023 due to issues with broken left hip. On 04/21/2023 LPA Calderon interviewed A1 for complaint. A1 states that R1 was taking too many medications and needed to be in a SNF and hospital for detox. A1 states that A1 did not refuse to allow R1 back into the facility, just that A1 needed the SNF to release R1 and then S2 would reassess the resident to see if R1 could return to the facility.

Allegation 2: Staff did not re-order residents’ medication timely.

It is alleged that staff did not re-order residents’ medication timely.
On 04/17/2023 LPA Calderon interviewed W1 for complaint. W1 states that facility ran out of R1 medications due to not ordering when they needed to. W1 states that R1 came into the facility with 1 month of medications and staff had enough time to reorder the medications for R1 needs. On 04/28/2023 LPA Calderon interviewed R1 for complaint. R1 states that R1 had a broken left hip prior to entering the facility. R1 states that R1 had one month of medications and for some unknown reason the facility staff refused to order new medications. On 04/21/2023 LPA Calderon interviewed A1 for complaint. A1 states that S2 and S3 attempted to reorder R1 medications and doctors refused to reorder unless R1 was seen by a doctor. On 04/21/2023 LPA Calderon interviewed S2-S3 who state that they called many doctors who would not give new prescription for R1 with out new evaluation. S2-S3 state that R1 was taking too many medications and needed to be in hospital for detox prior to being seen by a new doctor for a new prescription. On 04/21/2023 LPA Calderon reviewed SNF paperwork and noted that LVN’s requested new prescriptions for R1, but this was refused until detox was done. On 04/28/2023 LPA Calderon interviewed R2-R12 for complaint. R2, R6 and R8 state that they have family members order new medications and do not need facility to help order new prescriptions. R3, R4, R5, R7, R9-R12 state that they have the facility work with their family members to order new medications and they have never run out of medications they need to take.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20230414082004

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: 04/28/2023

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

Allegation 3: Resident missed medications.

It is alleged that resident missed medications.
On 04/17/2023 LPA Calderon interviewed W1 for complaint. W1 states that R1 was with W1 at W1 home and 2 weeks and W1 had requested the MAR. W1 states that S2-S3 had noted that R1 had taken R1 medications when this was not possible. W1 states that the facility ran out of R1 medications, and it was not possible for R1 to take R1 medications and therefore R1 had to go to detox. On 04/28/2023 LPA Calderon interviewed R1 for complaint. R1 states that R1 was with W1 for some time and staff had not given W1 or R1 the medication R1 needed to take and R1 had to go to detox for some unknown reason. On 04/21/2023 LPA Calderon interviewed A1 for complaint. A1 states that R1 was given medications by S2-S3 when R1 was at the facility and A1 does not know what was done while R1 was at W1 home. On 04/21/2023 LPA Calderon interviewed S2-S3 for complaint. S2-S3 state they were in contact with W1 regarding R1 medications needs. S2-S3 state that W1 did not have time to deal with R1 medication needs and advised S2-S3 to do what they could do. S2-S3 state that they could not order new medications without a doctor’s prescription and noted in the MAR when R1 had taken R1 medications and when R1 did not take the medications needed. On 04/21/2023 LPA Calderon reviewed the MAR for R1. MAR suggest that when R1 was in the facility R1 was given medications needed per doctor prescription. MAR noted that S2-S3 had documented when R1 took R1 medications, when R1 missing taking and when R1 refused to take R1 medications. On 04/28/2023 LPA Calderon interviewed R2-R12 for complaint. R2, R6, R8, R10 and R12 all state that they take their own medications without any help from staff and R3-R5, R7, R9 and R11 state that staff has never missed giving their medications every day.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

A face-to-face meeting was conducted with Administrator Amalia Esquivas, and a hard copy was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3