197603784-12-9-2024-28-AS-RORN-DBUPSY-20241211103503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603784
Report Date: 12/09/2024
Date Signed: 12/09/2024 11:03:43 AM

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
12/03/2024 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241203220738

FACILITY NAME:	FAITH MANOR		FACILITY NUMBER:	197603784
ADMINISTRATOR:	CLAREL MARTINE		FACILITY TYPE:	735
ADDRESS:	1832 SOUTH ARLINGTON AVE.		TELEPHONE:	(323) 737-2310
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90019
CAPACITY:	21	CENSUS: 17	DATE:	12/09/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Administrator Clarel Martine		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensning Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation listed above. LPA met with staff Tompi Sihamau and the purpose of the visit was discussed. Administrator arrived shortly afterwards.

LPA conducted the following during todays visit: LPA interviewed Staff #1-#2 (S1-S2), interviewed clients #1-5 (C1-C5), toured the physical plant which included client bedrooms #'s 1, 2, 3 , 4 , 7 , 8 , and 12. LPA observed the front and back yard. The investigation revealed the following:

In regards to the allegation: Facility is in disrepair, it is alleged that the facility is overall unkempt and in a state of disrepair that includes sanitary issues. (2) of (2) Staff interviewed denied the allegation. (3) of (5) Clients interviewed could not corroborate the allegation...

Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

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 28-AS-20241203220738

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: 12/09/2024

NARRATIVE

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(2) of (5) Clients stated there to be things broken and unkempt in the facility. Staff interviews stated clients will break things in their rooms and make messes but staff will do their best to make timely repairs and clean. Clients interviewed stated things break and they're not sure how. During the tour of the physical plant, LPA observed two (2) broken windows in the kitchen along with accumulated mess on the window sills. Windows were left broken and covered in paper. LPA observed two (2) holes in room #1 as well as a broken fire detector in room #12. Room #12 also had a broken tile in the center of the room. This shows the facility to be in disrepair. Based on interviews conducted with facility staff, facility clients, and LPA review of records and observations, 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 and 6 are being cited on the attached LIC 9099D.

Exit interview was conducted. A copy of the report and appeal rights were provided and discussed.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20241203220738

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: 12/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/23/2024 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087 Buildings and Grounds. (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This was not met as evidenced by:	1 2 3 4 5 6 7	Facility to repair broken windows, holes in the wall and tile mentioned as well as clean the window sills of the kitchen. Proof to be provided to LPA via pictures by POC due date.
	8 9 10 11 12 13 14	LPA observed broken windows in the kitchen, holes in the walls of room #1 and #12, broken smoke detector in room #12, all of which pose a potential health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC9099 (FAS) - (06/04)

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