191671691-4-25-2022-11-AS-MVAO-CF6UH9-20220607153534

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 04/25/2022
Date Signed: 04/25/2022 08:56:40 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
04/21/2022 and conducted by Evaluator Don Senaha

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220421103732

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: 110	DATE:	04/25/2022
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator - Amalia Esquivias		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Unqualified staff providing resident care.

INVESTIGATION FINDINGS:

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On 04/25/2022 Licensing Program Analyst (LPA) Don Senaha initiated an unannounced complaint investigation for the allegation listed above. LPA met with Administrator Amalia Esquivias and explained the purpose of today’s visit and conducted a risk assessment.

The investigations consisted of the following: LPA requested resident roster, staff roster, physician reports, needs and service plans, medication administration records, ID/Emergency contacts and admissions agreements. LPA interviewed residents (R1-R11), staff (S1-S5) and witness (W1-W2).

A plant inspection of the facility was conducted on 04/25/2022. There were no deficiencies noted during the visit.

Investigation revealed:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

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-20220421103732

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: 04/25/2022

NARRATIVE

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Allegation: Unqualified staff providing resident care.

It is alleged that unqualified staff is providing resident care.

(10 of 11) Residents stated their daily care needs are being met. (10 of 11) Residents stated they are treated well at the facility by staff. Resident (R2-R3, R5-R7, R11) stated medications are given by the med-techs with no issues and never had any reactions to medications.

Administrator Amalia Esquivias and staff (S1-S5) stated all medications are administered by the med techs or if necessary, by the LVN. Staff (S1-S5) stated staff (S1-S5) get along with all the residents. Majority of the staff (4 out of 5) stated they have never seen any type of adverse reaction to medications given to residents. Staff (S3-S4) stated they would report to the med techs if there was any reaction to medications from a resident. Staff (S1-S2, S5) stated they would check on the resident and determine next steps necessary for the safety and security of the resident.

Witness (W1-W2) stated resident (R1) makes a lot of accusations about care and supervision but there have been no merits or proof.

LPA received training documents for medication training for med techs. LPA received in service training from outside agency for medication, ADLs and Elder abuse.

Based on LPA’s 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.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC9099 (FAS) - (06/04)

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