191671691-5-27-2022-11-AS-UCOL-CG8SXS-20220711141625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 05/27/2022
Date Signed: 05/27/2022 02:53:56 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
05/07/2021 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20210507142318

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: 109	DATE:	05/27/2022
		UNANNOUNCED	TIME BEGAN:	02:18 PM
MET WITH:	Francisca Vallejo		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Questionable death

INVESTIGATION FINDINGS:

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On 05/27/22 Licensing Program Analyst (LPA) Jade Jordan conducted a subsequent visit to deliver the findings, based on Allegation “Questionable Death” Dated 05/10/21. LPA was met by Facility Assistant Administrator, and the purpose of the visit was explained.

Investigation Consisted Of : Service Request Sent to Investigation Branch (IB) to Investigate Nature of Allegations, Assignment being accepted By IB investigator, Interviews Conducted with Staff, Residents, Reporting Party, Health Department Representative, Record Review of Medical Documents , Supplemental Document to support allegations such as emails, and text messages.

*****Continued on 9099 C*****************

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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-20210507142318

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: 05/27/2022

NARRATIVE

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Regarding Allegation: “Questionable Death”

The Investigation conducted by IB Investigator Dennis Douglas revealed that the facility Crofton Manor had two outbreaks of Covid-19, in the year 2020. It was alleged that the facility was not taking necessary precaution during the early stages of Pandemic, in 2020. The outbreaks were among both staff, and residents in care. Interviews conducted with 14 Staff generally stated that they had observed staff practicing Social Distancing, Wearing Masks, and if sick/ confirmed Covid positive, not to return to work, until cleared.

Residents interviews R2-R5; Generally stated they did not observe any confirmed Covid-19 Resident(s) out of their rooms walking through out the facility.

Interviews with Administrator Stated that when the facility received their first case of Covid-19; in May of 2020, they contacted Department of Public Health Long Beach. The Department of Health Performed weekly Testing, on staff and residents. Testing was performed until facility was clear, In August of 2020. The second outbreak was not until December of 2020.

Record Review that the facility notified licensing, and Department of Public Health in 2020 of first and continued outbreaks. Mitigation Plans were put in place to address epidemic outbreaks or communicable diseases specific to Covid-19, but were not required to be put into place by Community Care Licensing Division (CCLD) until 01/24/21.

R1 was admitted to the hospital several times for underlying health conditions, beginning 10/10/20, until their death on 05/01/21. The department finds that cause of death was not due to Negligence.

Based on Interviews, Record Review, and Observation the Department 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.”

An Exit interview conducted, copy of this report provided. No Citations issued during this visit.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC9099 (FAS) - (06/04)

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