191671691-4-18-2024-11-AS-EMAZ-D4WUMP-20240503154239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 04/18/2024
Date Signed: 04/18/2024 04:39:00 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
04/10/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20240410104942

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: 116	DATE:	04/18/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:			TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff are not taking proper measures to maintain facility free of roaches
Facility staff are not following infection control requirements

INVESTIGATION FINDINGS:

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On 04/18/24, Licensing Program Analyst, Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with Administrator, Amalia Esquivias, and the purpose of today’s visit was explained.

During today’s visit LPA toured the facility, interviewed Staff (S1-S12), interviewed Residents (R1-R12), and received documents pertinent to the investigation. Documents received and reviewed include a Staff Roster, Resident Roster, Orkin Pest control receipts, Infection Control Plan, and cleaning schedule.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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-20240410104942

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: 04/18/2024

NARRATIVE

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Allegation: Facility staff are not taking proper measures to maintain facility free of roaches
It is alleged the facility has a roach infestation and are seen in the hallway and it has been six months since the last pest control service was provided.
During record review, LPA received and reviewed the facilities Service Reports from Orkin that show service dates on 04/03/24, 03/25/24, 02/21/24, 02/09/24, 01/17/24, 01/03/24, and 12/21/23. LPA observed on the Service Reports, in the comments about the day’s service, states “no signs of rodent or crawling insect activity were found during this visit.” During the facility tour, LPA did not observe any signs of insects inside the facility. During interviews with the Administrator S1 stated there is an exterminator through Orkin who comes in every two weeks or as needed to treat. During interviews with Staff S1-S12, they were asked if they have seen any insects (besides gnats and flies) inside of the facility in the past six (6) months, twelve (12) out of twelve (12) stated they have not seen any insects inside the facility. Additionally, during interviews with Staff S1-S12, were asked what procedures are there to keep the facility free of insects, twelve (12) out of twelve (12) stated they clean every room in the facility daily, take out the trash from every room daily, vacuum, sweep, and mop all rooms to ensure there are no food crumbs on the floor, and to remind all residents and staff to try to keep doors closed so nothing can get inside. During interviews with Residents R1-R12, were asked if they have seen any insects in the facility recently, R1, R3, R5, R7, and R10 stated they have not seen a cockroach or water bug inside for a few months and R2, R4, R8, R9, R11, and R12 have not seen a cockroach or water bug inside the facility at

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 11-AS-20240410104942

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: 04/18/2024

NARRATIVE

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any time. Additionally, during an interview with Residents R1-R12, were asked if they know if the facility has an exterminator they use, seven (7) out of twelve (12) stated they have seen an exterminator at the facility.
During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Facility staff are not following infection control requirements

It is alleged the pads on the patio chairs in the sunroom have not been cleaned, they have been soiled with feces and urine and staff only flip the pad over.
During the facility tour, LPA observed all common room and furniture to be clean. During file review, LPA received and reviewed the facility’s Daily Disinfecting Logs that show what has been cleaned, when and initialed by who did it. During interviews with Staff S1-S12, were asked how fabric furniture is cleaned if a resident has an accident, twelve (12) out of twelve (12) stated maintenance takes the piece of furniture outside to clean it and bring it back in when it is dry. During an interview with Staff S1-S4, were asked how the fabric furniture is cleaned, four (4) out of four (4) stated a machine is used to clean it. Additionally, S2, and S4 stated they use the Extractor to clean the fabric material which is like a carpet cleaner and the chair is placed in the sun to dry. During interviews with Residents R1-R12, were asked if the common rooms and furniture were cleaned regularly, eleven (11) out of twelve (12) stated they see staff cleaning the common rooms

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20240410104942

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: 04/18/2024

NARRATIVE

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multiple times a day. Additionally, twelve (12) out of twelve (12) stated they have seen the furniture outside drying once in a while.
During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

During today’s visit LPA did not observe or cite any deficiencies.

An exit interview was conducted with Assistant Administrator, Francisca Vallejo, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC9099 (FAS) - (06/04)

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