191671691-1-11-2022-11-AS-EMAZ-CDAVL4-20220408163121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 01/11/2022
Date Signed: 01/11/2022 02:38:42 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
01/06/2022 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20220106133213

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:	DATE:	01/11/2022
		UNANNOUNCED	TIME BEGAN:	10:14 AM
MET WITH:	Amalia Esquivas		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Illegal eviction

INVESTIGATION FINDINGS:

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On 1/11/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced complaint visit at this facility. LPA met with Amalia Esquivia, Administrator, and explained the purpose of today's visit is to conduct and investigation into the allegation listed above. LPA was granted entrance to facility.

The investigation consisted of the following: LPA interviewed Amalia Esquivia and requested and received the following documentation: staff and resident rosters, ID/Emergency information, physician’s assessment and other documents in association with the allegations.

Evaluation Report continues on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022

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-20220106133213

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: 01/11/2022

NARRATIVE

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NVESTIGATION REVEALED THE FOLLOWING:
Allegation: Illegal eviction.
It is alleged facility evicted R1 (Resident 1) illegally. LPA Spoke to administrator Amalia Esquivia who states no eviction notices have been served to any of the residents. Administrator Esquivia stated facility feels that R1 needs a higher level of care at this time, but they have not started eviction procedures for them. As R1 is currently in a medical facility, resident was advised to continue to receive higher level of care through skilled nursing facility. Administrator has communicated with R1’s doctor and family, who both agree that R1 needs a higher level of care than what the facility can provide, with the doctor adding that they felt it was unsafe for the resident to return to the facility at this time. LPA spoke to R1, who confirmed no eviction was served by the facility staff.

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022

LIC9099 (FAS) - (06/04)

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