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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 04/30/2025
Date Signed: 04/30/2025 03:30:59 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
04/24/2025 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20250424132231
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: 115DATE:
04/30/2025
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:ADMINISTRATOR AMALIA ESQUIVASTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not follow procedures to mitigate the spread of illness
INVESTIGATION FINDINGS:
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On 04/30/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Crofton Manor Inn and was greeted by Administrator Amalia Esquivias (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 finding pertaining to the above-mentioned allegation.

The investigation consisted of the following: LPA Calderon interviewed Staff S1-S6, resident R1-R12. LPA Calderon obtained the following records: Infection Control Plan (dated 06/29/2024), Cleaning Schedule (dated 12/2024 to 01/05/2025), incident report (dated 12/04/2024 to 12/18/2024), In-service training (dated 11/25/2024 to 03/25/2025).

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
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-20250424132231
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: 04/30/2025
NARRATIVE
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Regarding the Allegation: Staff do not follow procedures to mitigate the spread of illness.

This complaint alleged that the facility did not mitigate the spread of Covid19. LPA Calderon toured the facility with S1. LPA Calderon noted staff cleaning floors, bathrooms and rooms. LPA Calderon inspected the dining room and kitchen area and noted that the kitchen and dining rooms were very clean. LPA Calderon noted some staff wearing masks. LPA Calderon did not notice any resident’s that looked or acted sick. Record review indicate the following: Infection control plan indicate that the facility is prepared for any covid19 outbreak. Incident report indicates that the facility had a covid19 outbreak from 12/04/2024 to 12/18/2024 in which 23 residents and 5 staff tested positive for covid19. 23 residents were isolated from other residents and 5 staff were sent home. All residents and staff were tested per the infection control plan. In-service records indicate that staff were given covid19 training. Daily disinfecting log indicate that all common areas have been cleaned. Interviews indicate the following: 6 out of 6 staff deny the allegation. 6 out of 6 staff indicate there was a covid19 outbreak December 2024. 6 out of 6 staff indicate that the infection control plan was followed. 12 out of 12 residents deny the allegation. 2 out of 12 residents indicated that they tested positive for covid19 and were isolated from other residents.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not follow procedures to mitigate the spread of illness” is found to be UNSUBSTANTIATED.

No deficiencies cited during today's visit.



An exit interview was conducted, and a copy of the Complaint Report were provided to the Administrator Amalia Esquivas (S1).
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
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