191671691-3-2-2022-11-AS-MVAO-CDWQXH-20220428123333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 03/02/2022
Date Signed: 03/02/2022 03:49:13 PM

Unsubstantiated

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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2022 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20220224172616

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: 99	DATE:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Amalia Esquivias		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal belongings.
Staff mistreated resident.

INVESTIGATION FINDINGS:

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On 03/02/22 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced complaint investigation, regarding the allegations above. LPA was met by Facility Administrator, and the purpose of the visit was explained.

The investigation consisted of : Interviews with Residents in Care, Interview with administrator, staff resident roster, incident report and physical tour.

Regarding Allegation: Staff did not safeguard resident's personal belongings.
RP/R1 stated that when they returned the facility after being gone their room was locked with a Doughnut on the doorknob. RP/R1 stated that they believed someone had been in their room and named that only 3 people had the key. R1/RP stated that the Blue Ray DVD player in their room was no longer functioning. The door of the Dvd player was not opening, although plugged in and green light reflected that it was on.
R1/RP stated that there was no physical damage to the Blue Ray Player, but believed someone specifically staff, may have tampered with it because it was under 1 year old, and that they did not use it that often. ****** 9099 C Continued*******************************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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-20220224172616

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
MONTEREY PARK, CA 91754

FACILITY NAME: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 03/02/2022

NARRATIVE

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Interviews with R1/Rp revealed that to their knowledge no other items in their room were broken, or missing, or malfunctioning. Interviews with Residents in Care R2-R10 revealed, that all generally stated no one including staff has tampered with their personal belongs, such as Tv’s , DVD Players, Electronics or other personal items. Interviews with Administrator stated that they had one resident who had been out of the facility, and placed in skilled nursing for about 3 months. During that time, the Administrator placed a lock on the door in the shape of a doughnut, so that no one could enter the room to touch residents personal belongs. Administrator stated they have not received any complaints from any current or former residents about a blue ray player not working, that was under their supervision.

Based on Interviews, observation and record review the Lpa finds that “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding Allegation: Staff mistreated resident.

Interviews with Rp/R1 revealed that for 1 month, there was a clipboard placed in their room, that was used by staff to write the services performed. RP/R1 stated that they told the administrator that staff were taking 15 mins to write things down, that maybe took 2 mins, and that staff were basically taking a break. RP/R1 stated that they were not aware what the staff were writing. When they brought this to the Administrator’s attention. The Clipboard was taken out of their room. RP/R1 stated they were the only one with clipboards in the room, and feels that was discrimination. Interview with Administrator revealed that the clipboard was being used to track the amount of care needed, to determine if resident may need a higher level of care, then what the facility couldnt provide ( Copies of these forms were provided to LPA) there was a discussion with resident about what was being documented. Administrator stated the clipboard was taken out.

Interviews with Residents in Care R2-R10 generally stated that they do not feel mistreated, or discriminated by the staff.

An exit interview was conducted, and a copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

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