191671691-8-16-2024-11-AS-RORN-D9PUC4-20241003152720

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 08/14/2024
Date Signed: 08/16/2024 12:54:34 AM

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
08/05/2024 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20240805161857

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:	08/14/2024
		UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Amalia Esquivias		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff retaliated against resident in care.
Wrongful Eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, August 14, 2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is not cleared of COVID-19 infection. LPA Bunker met with Marketing/LVN Claudia Esquivias and spoke to Administrator Amalia Esquivias via telephone who arrived at the facility later. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: LPA Bunker interviewed staff members 1-2 (S1-S2) and residents 1-8 (R1-R8). LPA asked questions relevant to the nature of the complaint. S1-S2 and R2-R8 stated staff do not retaliate against residents under their care. S1-S2 stated that the resident did not receive a wrongful eviction. LPA Bunker reviewed the following documents: Admission Agreement, Resident Roster, Staff Roster, Appraisal & Needs Service Plan, Physicians Report, Identification and Emergency Information, Unusual Incident Reports, and other documents associated with this complaint. The investigation also included a facility tour. See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

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-20240805161857

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: 08/14/2024

NARRATIVE

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Continued LIC9099-C page 2

Allegation #1: Staff Retaliation Against Resident in Care

A resident alleged that they had been physically and psychologically abused by another resident and that the administrator failed to report the abuse. The resident stated that this abuse has been ongoing for two years and that the administrator has been notified of these incidents multiple times over the years. The resident informed the Ombudsman that the facility took no action to prevent further abuse.

Staff members S1-S2 stated that there is no retaliation against the resident in care and that they have gone above and beyond to assist the resident. They also confirmed that they have communicated with the resident's families or responsible parties, Community Care Licensing, and all appropriate agencies in a timely manner regarding the above incident.

Resident R1 reported enjoying living at the facility, finding 99% of the staff to be helpful and accommodating. R1 recounted a recent incident that occurred outside of the facility involving Resident R2, where R2 had a history of taunting R1. R1 claimed that they informed the staff, who then informed management, but felt that no action was taken to remove R2 from the facility due to R2's behavior.

R1 explained that Administrator S1 is involved in every incident and that both R1-R2 have been counseled by S1 regarding their behaviors. S1 suggested that R1 document the dates and times of each incident, but R1 found this too time-consuming and did not record any of the incidents involving R2. R1 acknowledged that facility staff have been responsive and did not believe that a lack of supervision was the cause of these incidents. R1 expressed frustration that R2 remains at the facility.

R1 mentioned that law enforcement had been dispatched for several incidents involving R2, with S1 assisting in notifying the authorities. R1 refused medical treatment for each incident involving R2, as there were no major physical injuries. R1 stated that S1 had offered to move R1 to a different floor, but R1 declined the offer.

See continued LIC9099-C, page 3

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20240805161857

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: 08/14/2024

NARRATIVE

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Continued LIC9099-C page 3

Allegation #2: Wrongful Eviction:

Staff members 1-2 (S1-2) stated resident was never wrongful eviction. S1-S2 stated that the resident was placed on a 5150 hold due to statements made indicating a threat to self-harm, specifically mentioning, "If I had access to a gun, I would shoot myself." The resident had called the Long Beach Police Department (LBPD) multiple times, expressing an intent to self-harm. In response, staff contacted the LBPD, as the resident reiterated a desire to die and mentioned the potential to shoot themself. According to S1-S2, no police report was left by the officers, but the decision to place the resident on a 5150 hold was based on the resident's aggressive behavior, not in retaliation for any previous reports of abuse.

S1 and S2 further clarified that the resident is permitted to return to the facility and that staff are not contributing to any additional emotional trauma. The resident has not received either a verbal or written eviction notice, and the claim of wrongful eviction is denied by S1-S2.

The investigation consisted of the following:
According to S1-S2, the facility is proactive and has been working with R2's family representative and the Assisted Living Waiver (ALW) representative to relocate R2 to another assisted living facility. S1-S2 stated since R1 is at a skilled nursing facility, the environment at the facility has been peaceful and R2 is still residing at the facility.

According to R1's Physician's Report dated 03/30/23, R1 is in fair physical condition, can self-care, and is predisposed to aggressive verbal behavior. R2's Physician's Report dated 10/19/23 revealed that R2 is in fair physical condition, can self-care with assistance, and is in a stable mental status.

S1-S2 stated they reported the special incident reports to all the appropriate agencies in a timely manner. An analysis of Unusual Incident Reports dated 04/10/24, 05/09/24, and 07/14/24, addressed to the Long-Term Care Ombudsman (LTCO), Adult Protective Services (APS), Community Care Licensing (CCL), and family members, indicates that there is insufficient evidence to corroborate the allegations mentioned above.

See continued LIC9099-C page 4

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20240805161857

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: 08/14/2024

NARRATIVE

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Continued LIC9099-C page 4

S1-S2, emphasizing the facility's zero-tolerance policy on abuse and its commitment to resident welfare and dignity. S1-S2 stated staff does not engage in any form of retaliation against residents and stated that the resident never received a wrongful eviction notice. S1-S2 stated that the facility staff takes all necessary precautions to ensure that residents are safe and protected from harm.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC9099 (FAS) - (06/04)

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