191671691-12-11-2023-11-AS-EMAZ-CZKSRN-20240117130637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:16:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
12/04/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20231204154801

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: 117	DATE:	12/11/2023
		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

Staff did not safeguard resident's funds

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 Crofton Manor Inn facility on 12/11/2023 and was greeted by Administrator Amalia Esquivas (A1). LPA Calderon spoke to A1 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.

During this investigation, LPA Calderon interviewed A1, S1-S2 and interview R1-R12. These interviews were conducted on 12/11/2023. On 12/11/2023 LPA Calderon requested copies of the following: P&I Records for R1-R5 (date 2023), physician orders for R1(date 4/13/2020). ISP Individual Service Plan for R1 (date 3/7/2022), Billing history for R1 (date 2/28/2021 to 8/31/2022), Copies of Stimulus check for R1 (date 2/8/2021 and 9/8/2021) On 12/11/2023 LPA Calderon toured the facility.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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-20231204154801

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 12/11/2023

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

Regarding Allegation #1: Staff did not safeguard residents’ funds.

This complaint alleges that the facility staff cashed R1 stimulus check in 2022. LPA Calderon conducted an interview with Amalia Esquivas A1. A1 states that S1 keeps records of all deposits received for residents and that per their records no stimulus check was received in 2021 or 2022 for $1400.00. A1 states that S3 would not take or cash a resident check. A1 states that R1 would sometimes deposit R1 checks, but for most of the time staff would deposit all checks and keep accurate records. A1 states that they keep records of all monies received from resident’s accounts including R1. LPA Calderon conducted an interview with S1-S2. S1 states that S1 keeps records of all deposits and checks received by the facility. S1 states that S1 nor S2 did not received a $1400.00 stimulus check from the US Treasury that R1 claims. S1 states that they did receive 2 stimulus checks for $600.00 each in 2021 and the money was deposited into R1 account. S1 states that S2 did not handle the stimulus checks as S1 was working at the time the checks came into the office. S1 states that S2 would only handle the checks when she was not in the office but would not make any deposits. S1 states that S2 made A1 and S1 aware of R1 accusation of the missing $1400.00 check and A1 and S1 investigated and could not confirm that any check for that amount was received. S2 states that R1 spoke to S2 and accused S2 of taking R1 stimulus check. S2 states that S2 advised A1 and S1 of the accusation by R1 and there is no truth in what R1 is claiming. S2 states that S2 did not handle R1 stimulus check and at that time in 2022 S2 was front desk help and could not have cash any resident’s check. S2 states that R1 is confused, and the facility has records of each check received and deposited. LPA Calderon conducted an interview with R1-R12 on 12/11/2023. R1 states that R1 received a US treasury check for $1400.00 in 2022 and that R1 signed the check and S2 cashed the check and did not give R1 any money. R1 states that normally S1 handles R1 checks and S1 would deposit R1 checks and pay rent with the money. R1 states that R1 is not confused and R1 complained to A1 with no action taken. R1 states that R1 does not have any record of the $1400 check that R1 signed. LPA Calderon conducted an interview with R2-R12 on 12/11/2023. 11 out of 11 residents state that staff deposits their checks, and they can obtain money by asking S1. 11 out of 11 residents state to have no issues with S1 and their money. On 12/11/2023 LPA Calderon reviewed resident cash resources (P&I) (date 12/10/21 to 7/29/2022) for R1, records show 12 withdraws by R1, none after 7/30/22 after resident moved to Edgewater. Reviewed cash resources (P&I) records (date 2023) for R2-R4.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20231204154801

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 12/11/2023

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

LPA Calderon noted deposits and withdrawals and confirmed by staff for each resident. LPA Calderon reviewed billing history (dated 2/28/21 to 8/31/22) for R1, 2 stimulus checks for $600.00 dated 2/8/21 and 9/8/21). Records note deposits received from resident and resident son for different amounts for R1. Reviewed deposit logs (date 3/1/21 to 6/1/22), noted 14 deposits for R1. None found for $1400.00 in 2021 or 2022.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of “Staff did not safeguard residents’ funds” is found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Amalia Esquivas (A1).

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3