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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603784
Report Date: 09/14/2021
Date Signed: 09/14/2021 03:44:08 PM

Substantiated


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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/23/2020 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200423122249
FACILITY NAME:FAITH MANORFACILITY NUMBER:
197603784
ADMINISTRATOR:CLAREL MARTINEFACILITY TYPE:
735
ADDRESS:1832 SOUTH ARLINGTON AVE.TELEPHONE:
(323) 737-2310
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:21CENSUS: 21DATE:
09/14/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Clarel MartineTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility has pests
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced subsequent complaint visit to deliver complaint investigation findings. LPA met with Administrator Clarel Martine and explained the reason for the visit.

The investigation consisted of: On 4/30/20, LPA Rivas conducted a telephone interview with Administrator Clarel Martine and Client 1's (C1) family member. LPA Rivas requested copies of Special Incident Report for 04/10/20 involving C1 and C2, LIC 500, Appraisal Needs and Services Plans for C1 & C2, Public Guardian contact information for C2, Conservatorship documents for C2, Pest Control Maintenace invoice for April 2020, Copy of menu for the last 30 days, copy of Activity Calendar on 4/30/20. On 6/9/20, LPA Gonzalez interviewed C1 by phone. On 6/17/21, LPA Luis Mora conducted phone interviews with Administrator Clarel Martine,


(See LIC9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 28-AS-20200423122249
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAITH MANOR
FACILITY NUMBER: 197603784
VISIT DATE: 09/14/2021
NARRATIVE
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Staff 1- 2 (S1-2) and C3-8. LPA Mora also requested and received copies of Pest Control Maintenance invoices for 1/2020 - 3/2021, Facility Menu, Facility Activity Calendar and Client and Staff Rosters. On 9/14/21, LPA Gonzalez collected copies of Staff and Client rosters, interviewed C9-13 and conducted a tour of the facility which included the facility kitchen and the outside of the facility and the following client rooms: Room #2, #3, #5 and #9. LPA additionally attempted to interview C1's family member by telephone.

Investigation revealed the following: Regarding allegation, Facility has pests, it is alleged that there are bed bugs at the facility. Interviews with Administrator Martine revealed that the facility gets treated monthly but not because they have any bed bugs at the facility but for prevention treatment. Administrator denies that there have been bugs or that their are any bed bugs at the facility. Interviews with staff revealed that there have been bed bugs as recent as early June 2021 and also last year in 2020 but they were treated by bringing in Pest Control, treating the affected areas and washing the sheets. S2 stated that the bed bugs were not on the beds but on the floor and on clients clothes. S2 stated that they treated the affected sheets and clothing with spray and also washing the items. 1 of 13 clients interviewed stated that there have been bed bugs at the facility but thinks they are gone now. 1 of 13 clients stated that they have seen bed bugs in the past but immediately changed their mind and stated that there are no bed bugs at the facility. 10 of 13 clients interviewed stated that there are no bed bugs at the facility, and stated that the facility staff clean their rooms on a daily basis and laundry and linens are cleaned once a week. LPA Gonzalez conducted a tour of 4 client rooms and did not see any evidence of bed bugs and observed client's beds to be clean and have appropriate mattress protectors.

Based on interviews conducted with facility staff and one facility client that verified that there have been bed bugs at the facility as recent as early June 2021 and also sometime in 2020, the preponderance of evidence standard has been met, therefore the above stated allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview was conducted with Administrator Clarel Martine. A copy of the report and appeal rights were provided to Administrator.
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20200423122249
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAITH MANOR
FACILITY NUMBER: 197603784
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2021
Section Cited
CCR
80087(a)(1)
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Buildings and Grounds. Licensees shall take measures to keep the facility free of flies and other insects.


This requirement is not met as evidenced by:
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Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulations. Adminstrator to submit a faxed or mailed copy of POC by due date.
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Based on interviews conducted with facility staff and one facility client that verified that there have been bed bugs at the facility as recent as early June 2021 and also sometime in 2020, this poses a potential personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/23/2020 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200423122249

FACILITY NAME:FAITH MANORFACILITY NUMBER:
197603784
ADMINISTRATOR:CLAREL MARTINEFACILITY TYPE:
735
ADDRESS:1832 SOUTH ARLINGTON AVE.TELEPHONE:
(323) 737-2310
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:21CENSUS: 21DATE:
09/14/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Clarel MartineTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Lack of supervision resulted in resident getting injured by another resident
Facility does not provide a comfortable temperature for residents
Facility does not provide residents healthy foods
Administrator is not present at facility a sufficient amount of time
Facility does not provide residents' activities
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced subsequent complaint visit to deliver complaint investigation findings. LPA met with Administrator Clarel Martine and explained the reason for the visit.

The investigation consisted of: On 4/30/20, LPA Rivas conducted a telephone interview with Administrator Clarel Martine and Client 1's (C1) family member. LPA Rivas requested copies of Special Incident Report for 04/10/20 involving C1 and C2, LIC 500, Appraisal Needs and Services Plans for C1 & C2, Public Guardian contact information for C2, Conservatorship documents for C2, Pest Control Maintenace invoice for April 2020, Copy of menu for the last 30 days, copy of Activity Calendar on 4/30/20. On 6/9/20, LPA Gonzalez interviewed C1 by phone. On 6/17/21, LPA Luis Mora conducted phone interviews with Administrator Clarel Martine,


(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20200423122249
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAITH MANOR
FACILITY NUMBER: 197603784
VISIT DATE: 09/14/2021
NARRATIVE
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Staff 1- 2 (S1-2) and C3-8. LPA Mora also requested and received copies of Pest Control Maintenance invoices for 1/2020 - 3/2021, Facility Menu, Facility Activity Calendar and Client and Staff Rosters. On 9/14/21, LPA Gonzalez collected copies of Staff and Client rosters, interviewed administrator, C9-13, and conducted a tour of the facility which included the facility kitchen and the outside of the facility and the following client rooms: Room #2, #3, #5 and #9. LPA additionally attempted to interview C1's family member by telephone.

Investigation revealed the following: Regarding allegation, Lack of supervision resulted in resident getting injured by another resident, it is alleged that the facility does not have adequate staffing to provide adequate care and supervision to clients. It is alleged that at times only the cook and the cleaning staff are at the facility. Administrator Martine denied that the facility does not have adequate staffing. He stated that he always ensures that the facility is fully staffed to provide proper care and supervision to facility clients. He stated that there is always someone in the front desk as that is where clients go when they need something. Interviews conducted with facility staff revealed that the facility is adequately staff to provide proper care and supervision to clients. Interviews conducted with 9 out of 13 clients revealed that they believe there are enough staff on schedule. They stated that their rooms and the facility are cleaned on a daily basis and their laundry is done on a weekly basis. LPA reviewed facility schedule and observed that there is enough staff on schedule to properly oversee clients, facility operation and tend to clients daily needs. Based on interviews conducted with facility staff, facility clients, and LPA record review, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility does not provide a comfortable temperature for residents, it is alleged that facility does not have air conditioning, and when the weather is hot the facility is very hot and when the weather is cold the facility is very cold. Interviews conducted with facility administrator and staff revealed that the facility temperature is always kept at an acceptable temperature. Administrator stated that all rooms have a ceiling fan, there are additional fans that are used during the hot weather season and they also have heaters that are used during the cold weather season. Interviews conducted with 9 out of 13 clients revealed that the facility provides a comfortable temperature. 4 clients stated that the facility does provide additional fans and heaters when needed. LPA toured the facility and observed the facility to be at an appropriate temperature. LPA toured 4 client rooms and observed that the rooms were cool and all had a ceiling fan. Based on interviews conducted with facility staff, facility clients, and LPA observations, there was not enough supportive evidence to concur with the reported allegation.
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20200423122249
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAITH MANOR
FACILITY NUMBER: 197603784
VISIT DATE: 09/14/2021
NARRATIVE
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For the allegation, Facility does not provide residents healthy foods, it is alleged that the facility serves unhealthy food to clients. Interviews conducted with 9 out of 13 clients revealed that they are satisfied with the food service provided at the facility. They stated that the food is healthy, they receive three full meals and 1-2 snacks per day. Administrator stated that food is ordered weekly to ensure that there is enough food in stock for client's daily dietary consumption. LPA toured the facility kitchen and observed facility menu posted and observed an ample amount of food. There was enough food for 7 days non perishables and 2 day perishables. LPA observed the the facility serves meals that are well balanced with a selection of fruits and vegetables. Based on LPA observations, LPA review of facility menus, and statements gathered from interviews conducted with staff and clients there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Administrator is not present at facility a sufficient amount of time, it is alleged that the facility administrator is not physically present at the facility a sufficient amount of time. Interview conducted with facility administrator revealed that he is present at the facility everyday including weekends. He stated that when he is not at the facility he ensures that there is enough staff on schedule. He also stated that he is always on call. Facility staff interviewed revealed that there is enough staff on schedule and that the administrator is present at the facility everyday. LPA Gonzalez interviewed 4 clients on 9/14/21 who all stated that the administrator comes to the facility everyday and they believe he is at the facility a sufficient amount of time. LPA reviewed facility schedule and observed that the facility administrator is present at the facility a sufficient amount of time and also observed that there is enough staff on schedule to properly oversee clients, facility operation and tend to clients daily needs. Based on interviews conducted with facility staff, facility clients, and LPA record review, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility does not provide residents' activities, it is alleged that the facility does not have planned activities and does not take clients out on outings. Interview conducted with facility administrator revealed the facility does provide clients with activities such as card games, bingo, walks in the community, music, and movie nights. Administrator stated that due to the COVID-19 pandemic they did stop doing many activities as it was necessary for prevention, containment, and to abide and comply with mitigation measures as specified by the Centers for Disease Control and Prevention (CDC), the California Department of Public Health (CDPH), and local health departments. Administrator stated that they have recently started activities
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20200423122249
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAITH MANOR
FACILITY NUMBER: 197603784
VISIT DATE: 09/14/2021
NARRATIVE
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again. Staff interviewed stated that the facility does provide activities for the clients. 8 out of 13 clients that were interviewed stated that the facility does provide them with activities such as board games, bingo, walks in the community and movie nights. LPA observed and reviewed Monthly Activity schedules. Based on interviews conducted with facility staff, facility clients, and LPA observations/ review of records, there was not enough supportive evidence to concur with the reported allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Administrator Clarel Martine.
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7