191671691-1-19-2022-11-AS-AJKK-CC7VS3-20220304154051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 01/19/2022
Date Signed: 01/19/2022 10:30:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2022 and conducted by Evaluator Jey Cardenas

COMPLAINT CONTROL NUMBER: 11-AS-20220111103410

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: 104	DATE:	01/19/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Amalia Esquivas		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Illegal eviction
Residents not being provided adequate services.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced complaint visit at this facility. LPA met with Amalia Esquivia, Administrator, explained the purpose of today's visit, and conducted risk assessment.

The investigation consisted of the following: LPA interviewed Amalia Esquivia obtained copy of resident roaster, staff work schedules, R1 service logs, Individual service plan, physician report. Interviews conducted with residents.

It is alleged that R1 was illegally evicted. In addition during the time R1 lived at the facility, most recently residents were not being provided with service and assistance needed. R1 states that "staff would go on lunch break and there was no one available to assist."

Regarding allegation: Illegal eviction LPA Cardenas interviewed administrator, Amalia Esquivas who

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220111103410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 01/19/2022

NARRATIVE

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indicates that R1's was hospitalized, later discharged, and placed in a skilled nursing facility (SNF) for continued care. R1 is currently in a SNF; resident was advised to continue to receive higher level of care through SNF . Physician has indicated that R1 needs higher level of care with the doctor adding that they felt it was unsafe for the resident to return to the facility. LPA spoke to R1, who confirmed no eviction was served by the facility staff.

Regarding allegation: Residents not being provided adequate services. During interview with R1, resident indicates that at times residents are unable to get services nor assistance due to caregivers are on lunch. LPA Cardenas interviewed administrator, Amalia who indicates that none of the residents have complained that they aren't being provided with adequate services. Amalia states that lunch is 30 minutes and not all staff go to lunch at the same time. Amalia indicates that R1 needed constant assistance. LPA reviewed services log for the month of December 2021, logs show date and times with services being rendered. LPA observed that R1 request for services averaged eight (8) times per day. LPA reviewed staff schedule for weeks starting 01/23/2022 and ending 02/05/2022; LPA observed seven (7) caregiver staff on shift from 6:30am- 2:30pm; seven (7) caregiver staff from 2:30pm- 10:30pm and five (5) caregiver staff for overnight shift 10:30pm- 6:30am. On Sundays there is an additional staff on schedule in the event a staff calls out. There are two (2) CNA's and two (2) LVN's, a supervisor to assist residents. In addition there are administrative staff available to assist. During tour LPA observed staff throughout the facility assisting residents. LPA Cardenas interviewed residents, the majority of residents indicate that they feel they are being provided with adequate services. When resident needs staff assistance, staff is responsive for most part. One resident indicates that about three months ago, staff was called for assistance and it took staff 1/2 to render services. The majority of the residents indicate that staff respond and provide services within a reasonable time.

Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with Administrator Amelia and a hard copy was provided.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

LIC9099 (FAS) - (06/04)

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