191671691-3-19-2025-11-AS-UCOL-DFFSKZ-20250405135735

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 03/19/2025
Date Signed: 03/19/2025 04:20:23 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
03/13/2025 and conducted by Evaluator Socorro Leandro

COMPLAINT CONTROL NUMBER: 11-AS-20250313135625

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: 119	DATE:	03/19/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator - Amelia Esquivias		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff do not ensure adequate care and supervision is being provided
Staff do not safeguard residents personal items
Staff keep residents door locked

INVESTIGATION FINDINGS:

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On 03/19/2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Socorro Leandro and LPA Jose Anguiano conducted an initial unannounced complaint visit. LPAs met with Administrator Amelia Esquivias and the purpose of the visit was explained. LPAs were granted entry to the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

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 5

Control Number 11-AS-20250313135625

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: 03/19/2025

NARRATIVE

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The investigation consisted of the following:

On 03/19/2025, a facility tour was conducted, records were reviewed, and interviews were conducted. The facility tour consisted of the Memory Care Unit. Interviews consisted of 5 staff [Staff 1 (S1) to Staff 5 (S5) were interviewed] interviews, 5 resident [Resident 1 (R1) to Resident 5 (R5) were interviewed] interviews, and 7 witness [Witness 1 (W1) to Witness 7 (W7) were interviewed] interviews. Facility records reviewed consisted of Crofton Manor Inn Facility Plan of Operation, Theft and Loss Policy, Employee Roster, Resident Roster, and Resident Contact Sheet. Resident records reviewed consisted of Identification and Emergency Information, Physicians Reports, Unusual Incident Reports (UIRs), Resident Appraisal, Individual Service Plan & Preference, Individual Service Plan (R1, R2, R6, and R7 records were reviewed).

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20250313135625

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: 03/19/2025

NARRATIVE

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The investigation revealed the following:

Allegation: “Staff do not ensure adequate care and supervision is being provided”, it is being alleged that the facility does not provide adequate care and supervision for memory care residents. Interviews conducted with R1 to R5 revealed the following: 2 out 5 residents denied the allegation and 3 out 5 resident interviews were inconclusive. Interviews conducted with S1 to S5 revealed the following: 5 out of 5 staff denied the allegation. Interviews conducted with W1 to W7 revealed the following: 7 out of 7 witnesses denied the allegation. Records reviewed revealed the following: no UIRs were found indicating that care and supervision was not provided. Observations of the memory care unit on 3/19/2025 revealed the following: The department observed caregivers providing care and supervision to memory care residents such as conducting room checks, assisting residents in the bathroom, assisting residents with feeding, and repositioning residents. Based on interviews, records, and observations this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20250313135625

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: 03/19/2025

NARRATIVE

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Allegation: “Staff do not safeguard residents personal items”, it is being alleged that a resident goes into other residents rooms and takes their belongings, eats their food and staff does not safeguard residents personal items in the memory care unit. Interviews conducted with R1 to R5 revealed the following: 1 out 5 residents denied the allegation; 1 out of 5 residents agreed with the allegation and 3 out 5 resident interviews were inconclusive. Interviews conducted with S1 to S5 revealed the following: 5 out of 5 staff denied the allegation. Interviews conducted with W1 to W7 revealed the following: 7 out of 7 witnesses denied the allegation. Records reviewed revealed the following: no UIRs were found indicating that residents’ personal items have gone missing. Observations of the memory care unit on 3/19/2025 revealed the following: The department did not observe residents going into rooms that were not theirs. Based on interviews, records, and observations this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20250313135625

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: 03/19/2025

NARRATIVE

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Allegation: “Staff keep residents door locked”, it is being alleged that staff are locking residents inside their rooms in the memory care unit. Interviews conducted with R1 to R5 revealed the following: 2 out 5 residents denied the allegation and 3 out 5 resident interviews were inconclusive. Interviews conducted with S1 to S5 revealed the following: 5 out of 5 staff denied the allegation. Interviews conducted with W1 to W7 revealed the following: 7 out of 7 witnesses denied the allegation. Records reviewed revealed the following: no UIRs were found indicating that residents have been locked in their rooms. Observations of the memory care unit on 3/19/2025 revealed the following: all the resident rooms had an open door; the department did not observe locked or closed resident doors. Based on interviews, records, and observations this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated

No citations were provided.

An exit interview was conducted, and a copy of this report was left with the Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

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