191671691-5-29-2024-11-AS-MVAO-D5RT53-20240530142451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 05/29/2024
Date Signed: 05/29/2024 08:33:54 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2024 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240520091959

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:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Amaila Esquivias		TIME COMPLETED:	04:59 PM

ALLEGATION(S):

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Due to lack of supervision, resident is assaulting another resident.

INVESTIGATION FINDINGS:

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On 05/29/24, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to this facility and was greeted by Administrator #1 (A1: Amalia Esquivias). LPA Dabuet explained the purpose of today’s visit is to conduct an investigation into the allegation mentioned above and deliver findings.

The investigation consisted of the following: During today’s visit, LPA reviewed the following documents: Resident Roster; Facility Staff Roster; Resident #1- #2 (R1-R2)’s Physicians Report LIC 624A, Identification and Emergency Information LIC 601, Unusual Incident Reports LIC 624 and other documents associated with this complaint. An interview with residents #1-#10 (R1-R10), Administrator #1 (A1), Staff #1 (S1), and witnesses #1-#2 (W1-W2). There was a tour of the facility.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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 4

Control Number 11-AS-20240520091959

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 05/29/2024

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Due to lack of supervision, resident is assaulting another resident.

The details of this complaint alleged that due to lack of supervision, resident #1 (R1) was assaulted by resident #2 (R2). The complainant reported that (R1) was physically and emotionally abused by (R2) and informed (R1) that (R2) was not going to hit (R1) anymore, but (R2) hit (R1) with an electric wheelchair on purpose. The complainant stated (R1) reported the incident to law enforcement and claimed (R1) does not feel safe around (R1) especially when they both live in the same assisted living facility.

According to (R1)’s and (R2)’s Identification and Emergency Information LIC 601 (dated: 10/07/21 and 03/28/22), (R1) was admitted to Crofton Manor on 03/28/22, while (R2) was admitted to 10/08/21.

On 05/29/24, between 11:20 am – 11:50 am, the Department interviewed resident #1 (R1). (R1) claimed to like living at the facility and found 99% of the staff considered helpful and accommodating. (R1) explained an incident that happened most recently outside of the facility with (R2). (R1) explained that (R2) was never considered a friend and that (R2) has a history of taunting (R1). (R1) claimed that (R2) enjoyed harassing (R1) and continues to do so outside and inside the facility. (R1) claimed that (R1) would inform staff and that staff would inform management but felt nothing was done about removing (R1) from the facility due to (R1)’s behavior. (R1) explained that administrator #1 (A1) is involved in every incident, and both (R1) and (R2) have been counseled by (A1) for their behaviors. (A1) suggested that (R1) start writing down the dates and times of each incident. (R1) stated it was too time-consuming and did not record any of the incidents that have occurred with (R2). (R1) claimed that facility staff have been responsive and did not consider it was lack of supervision that may have caused these incidents with (R2). (R1) is frustrated that (R2) is being held back so long by the facility. (R1) stated that law enforcement had been dispatched for several of the incidents involving (R2) and that (A1) assisted with notifying the authorities. (R1) refused to seek medical treatment for every incident involving (R2) due to no major physical injuries were involved. (R1) confirmed that (A1) had offered to move (R1) to a different floor but declined.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240520091959

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 05/29/2024

NARRATIVE

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On 05/29/24, between 11:10 am – 11:20 am, the Department interviewed resident #2 (R2). (R2) claimed to to have no battles with any residents and get along with all. (R2) expressed that staff supervision is good. The staff are alert to prevent conflicts with other residents. (R2) denied having any issues with (R1). (R2) claimed to feel safe living at this facility.

On 05/29/24, between 09:38 am – 11:09 am, the Department interviewed residents #3-#10 (R1-R10). Eight (8) out of eight (8) residents felt safe in their living environment and were complimentary of staff. (R3-R10) have not witnessed any unacceptable behavior between residents. (R3-R10) claimed when on duty the staff are alert and responsive and will step in to prevent any unwarranted behaviors between residents. (R3-R10) reported the facility holds monthly Residents Council Meetings, and concerns are discussed. Suggestion Box is also available for residents who want to address any concerns anonymously.

On 05/29/24, between 09:00 am – 11:58 am, the Department interviewed administrator #1 (A1) and staff #1 (S1) both refuted this accusation. (A1) and (S1) both expressed that there is a history between (R1) and (R2). (A1) and (S1) claimed that (R1) and (R2) used to be friendly with one another as they were friends. (R1) and (R2) have been spotted inside the facility and outside to have engaged socially. Their friendship has ended, and they no longer communicate with one another. (A1) has consulted both (R1) and (R2) for their behaviors, and (R2) has been provided verbal warnings that may lead to termination of residency. (A1) claimed the last incident involving (R1) and (R2) was on 05/09/24. The incident happened outside the facility. (R1) claimed that (R2) intentionally bumped into (R1) with (R2)’s wheelchair. (R2) claimed it was not intentional that the act was an accident - the wheelchair was not working correctly. (A1) immediately notified the wheelchair company to examine (R2)’s wheelchair for repairs. While collecting statements from (R2), the Long Beach Police arrived and took statements from both (R1) and (R2). In inclusion, (R2) was ordered to stay away from (R1) and not to communicate or contact (R1) in the police report completed #24-23-424. (A1) stated that incident reports for (R1) and (R2) were submitted, and family representatives for both residents had been notified. (S1) claimed incidents involving (R1) and (R2), and (R1) declined to seek medical assistance. (A1) reported that both residents share the same floor and have been offered to move to different floors - both have refused to move. (A1) stated it is not due to lack of supervision our staff are trained to act to prevent violence amongst residents. Surveillance cameras are installed in all the common areas to capture unwarranted activities.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20240520091959

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 05/29/2024

NARRATIVE

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According to (A1) the facility is being proactive and has been working with (R2)'s family representative and Assisted Living Waiver (ALW) representative to relocate (R2) to another assisted living facility.

On 05/29/24, between 12:21 pm – 01:30 pm, the Department interviewed family representatives witnesses #1-#2 (W1-W2). (W1-W2) both confirmed to have been informed by (A1) of the incidents involving (R1) and (R2) and claimed these incidents were not due to a lack of supervision from the facility. (W2) confirmed that (R2) has agreed to be relocated to another assisted living facility and that (A1) is in the process of assisting in the procedure.

As a result of the Department reviewing (R1)'s Physicians Report LIC 602A (dated: 03/30/23), revealed that (R1) is in fair physical status, can self-care, and is disposed to aggressive verbal behavior. (R2)’s Physicians Reported (dated: 10/19/23), revealed (R2) is in fair physical condition, can self-care with assistance, and is in a safe mental status. An analysis of Unusual Incident Reports (dated: 04/10/24 and 05/09/24) addressed to the Long Term Ombudsman (LTCO), Adult Protective Services (APS), Community Care Licensing (CCL), and family members. Based on the information gathered, there is insufficient evidence to corroborate the allegation mentioned above.

Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned in this complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove NEGLECT/LACK OF SUPERVISION, “Due to lack of supervision, resident is assaulting another resident” did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited.

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

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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