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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603784
Report Date: 12/09/2022
Date Signed: 12/09/2022 12:36:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
12/17/2020 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201217094725
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: 19DATE:
12/09/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Clarel MartineTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility has infestation of bed bugs
Facility is unclean


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 12/24/20, LPA Gonzalez conducted a telephone interview with Administrator Clarel Martine and requested/ collected copies of Staff and Client Rosters. On 6/17/21, LPA Luis Mora interviewed Administrator Martine, Staff 1-2 (S1-2) and Clients 1-6 (C1-6) by telephone. On 11/30/22, LPA Gonzalez conducted a tour of entire facility including client rooms, dining room, kitchen, TV room, facility bathrooms, outside common area, and backyard. The following client rooms were inspected: Room #2, #3, #5, #8, #9, #10 and #11. LPA collected copies of Staff and Client Rosters, Pest Control Maintenace invoice for November 2020 - March 2021, and Copy of menu for the last 30 days,. LPA additionally conducted interviews with C7-12 and S3-4. LPA conducted a telephone interview with S5.

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

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
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 8
Control Number 28-AS-20201217094725
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAITH MANOR
FACILITY NUMBER: 197603784
VISIT DATE: 12/09/2022
NARRATIVE
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Investigation revealed the following: Regarding allegation, Facility has infestation of bed bugs, it is alleged that the facility has an infestation of bed bugs at the facility. Interview with Administrator Martine revealed that the facility gets treated monthly for prevention treatment. Administrator denies that there have been bugs or that there are any bed bugs at the facility. Interviews with staff revealed that there have been bed bugs and even though the facility treats them and gets rid of them some clients keep bringing items from outside of the facility that most likely have bed bugs. Staff stated that the facility is treated by bringing in Pest Control, treating the affected areas, removing and replacing affected mattresses and washing the bed linens/ sheets. Staff stated that they have treated affected sheets and clothing with spray and by also washing the items in very hot temperature. 1 of 12 clients interviewed stated that there are bed bugs at the facility. 11 of 12 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 observations of rooms #2 and #11, revealed and confirmed active bedbugs on two mattress covers and linens in each room. LPA review of pest control receipts did not show that the facility has been treated for bed bugs between November 2020 - March 2021. Receipts show that the facility has been treated for other pests.

For the allegation, Facility is unclean, it is alleged that the facility is very filthy. LPA conducted a tour of the facility which consisted of observations and inspection of client rooms, dining room, kitchen, TV room, facility bathrooms, outside common area, and backyard. The following client rooms were inspected: Room #2, #3, #5, #8, #9, #10 and #11. LPA observed the following: Facility walls and floors were dirty throughout the entire facility, window sills were dirty in the client rooms and the kitchen, hole on the wall in the common/ TV room, unused furniture in the back yard (balcony - located outside of room #10) along with a lot of leaves and debris, bathrooms were not clean and the toilet in the bathroom located downstairs was broken and in disrepair, observed shower curtains to be dirty and in disrepair, bathroom sinks were dirty and water on the floor as well as toilets dirty. Although interviews with staff and clients revealed that the facility is clean and that staff clean the facility once a day and as needed, LPA observations revealed that the facility is unclean.

Based on interviews conducted with facility staff, facility clients and LPA observations that verified that there have been bed bugs at the facility, and the facility is unclean, the preponderance of evidence standard has been met, therefore the above stated allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 28-AS-20201217094725
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAITH MANOR
FACILITY NUMBER: 197603784
VISIT DATE: 12/09/2022
NARRATIVE
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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
12/17/2020 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201217094725

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: 19DATE:
12/09/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Clarel MartineTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility has infestation of rodents
Facility staff failed to provide adequate food service
Facility does not have hot water
Residents are unkept
Facility has insufficient staffing to meet residents needs
Residents have illegal drugs in the facility
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 12/24/20, LPA Gonzalez conducted a telephone interview with Administrator Clarel Martine and requested/ collected copies of Staff and Client Rosters. On 6/17/21, LPA Luis Mora interviewed Administrator Martine, Staff 1-2 (S1-2) and Clients 1-6 (C1-6) by telephone. On 11/30/22, LPA Gonzalez conducted a tour of entire facility including client rooms, dining room, kitchen, TV room, facility bathrooms, outside common area, and backyard. The following client rooms were inspected: Room #2, #3, #5, #8, #9, #10 and #11. LPA collected copies of Staff and Client Rosters, Pest Control Maintenace invoice for November 2020 - March 2021, and Copy of menu for the last 30 days,. LPA additionally conducted interviews with C7-12 and S3-4. LPA conducted a telephone interview with S5.

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

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 28-AS-20201217094725
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAITH MANOR
FACILITY NUMBER: 197603784
VISIT DATE: 12/09/2022
NARRATIVE
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Investigation revealed the following: Regarding allegation, Facility has infestation of rodents, it is alleged the facility has an infestation of rodents. Interviews with Administrator Martine revealed that the facility does not have an infestation of rodents. He stated that he has not been notified by any clients or facility staff that there are rodents in the facility. Administrator stated that the facility gets treated by pest control monthly. Interviews with staff revealed that there are no rodents in the facility and that the facility gets treated monthly. 12 of 12 clients interviewed stated that there are no rodents at the facility. 8 of 12 clients interviewed stated that there are no rodents 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. 4 of 12 clients were not asked if there are any rodents in the facility, but did state 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 7 client rooms and did not see any evidence of rodents or any droppings indicating that there is an infestation of rodents in the facility. Based on interviews conducted with facility staff, facility clients, and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility staff failed to provide adequate food service, it is alleged that the facility clients are not properly fed. Interviews conducted with 12 out of 12 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, Facility does not have hot water it is alleged that facility does not have hot water. Interviews conducted with facility administrator and staff revealed that the facility does have hot water. Administrator stated that water is checked weekly to ensure that the water is always set a the required temperature that is between 105 F - 120F. Interviews conducted with 12 out of 12 clients revealed that the facility has hot water at all times. LPA toured the facility and observed the facility to be at an appropriate temperature. LPA measured the temperature in a bathroom located on the first floor and another bathroom on the second floor and both temperatures were 115F. 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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 28-AS-20201217094725
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAITH MANOR
FACILITY NUMBER: 197603784
VISIT DATE: 12/09/2022
NARRATIVE
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For the allegation, Residents are unkept, it is alleged that the facility clients are not clean and are unkept and the facility clients walk the streets without shoes, are dirty and look as if they have not showered. Interviews conducted with Administrator Clarel and facility staff revealed that clients are encouraged to take a shower everyday and are provided the proper hygiene products. They stated that many clients do not want to take a shower. Staff stated that they keep encouraging these clients but the clients do not listen or sometimes act as if they are taking a shower but still appear dirty. Staff stated that clients are allowed to leave the facility unsupervised and can go and come as they please because they are adults and are independent but stated that they do have to be back by curfew. Administrator and facility staff denied that clients leave the facility not wearing any shoes. Administrator stated that clients are able to bathe themselves and staff constantly remind and encourage those that do not like to bathe often but cannot be forced. LPA reviewed 6 client records which indicated that clients do not need assistance with bathing and can care for all personal needs. 6 out of 6 clients that were interviewed on 11/30/22, stated that they are provided with hygiene products when needed and that they do take showers. 2 clients stated that staff remind them to take showers and 4 clients stated that they do not need to be reminded about taking showers. LPA reviewed 6 client records and all indicated that clients do not need assistance with bathing and can care for all personal 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 has insufficient staffing to meet residents needs, it is alleged that the facility does not have adequate staffing to provide adequate care and supervision to clients. 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 as well as Assistant Administrator Pascalle Martine. He stated that he always ensures that the facility is fully staffed to provide proper care and supervision to meet the client's needs. Facility staff interviewed revealed that there is enough staff on schedule and that the administrator is present at the facility everyday. Administrator and staff stated that there are always two staff per shift including the night shift. 10 out of 12 clients that were interviewed revealed that there is enough staff on schedule to meet their needs and to supervise them. 10 clients stated that the administrator comes to the facility everyday and they believe he is at the facility a sufficient amount of time. 1 client stated that they did not know if there is enough staff and 1 client stated that they think there should be at least one more staff per shift. LPA reviewed facility
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 28-AS-20201217094725
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FAITH MANOR
FACILITY NUMBER: 197603784
VISIT DATE: 12/09/2022
NARRATIVE
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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, Residents have illegal drugs in the facility, it is alleged facility clients have illegal drugs in the facility and that clients purchase drugs outside of the facility. It is also alleged that a car drives up across the street and delivers drugs to the clients and clients return to the facility with the drugs. Interview with Administrator Martine revealed that drugs are not allowed in the facility and also stated that drug use is not allowed anywhere in the facility premises. He stated that he can not control what clients might do when out in the community but it does not happen inside of the facility. Administrator stated that he has not seen any car drive up to the facility and sell drugs to clients. He stated that clients are independent and do go out during the day and he does not know what they might buy out in the community. Administrator stated that facility staff conduct regular rounds and inspect client rooms to ensure that there is no illegal drugs or drug paraphernalia in the facility. Facility staff stated that clients do not use drugs in the facility and stated that drug use is not allowed at any time in the facility. Staff also stated that they have not seen a car drive up to the facility to sell drugs to clients and stated that they have not seen illegal drugs while conducting rounds of client rooms. Staff indicated that many clients do smell like marijuana when coming in from the community but stated that it is not allowed in the facility. n Interviews with 12 out of 12 clients stated that drug use is not permitted in the facility and deny that any client at the facility do drugs. 6 out of 6 clients that were interviewed on 11/30/22 stated that they have not seen or heard any clients purchase drugs from a car that drives up to the front of the facility. Administrator stated that the street in front of the facility is a very busy street and cars are there is constant car traffic throughout the day. 12 out of 12 clients stated that they have not seen anyone do drugs in the facility. LPA toured the facility including 7 client rooms and observed client rooms to be clean and LPA did not smell or observe anything that might be described as drugs. Based on interviews conducted with facility staff, facility clients, and LPA tour of client rooms and facility 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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 28-AS-20201217094725
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAITH MANOR
FACILITY NUMBER: 197603784
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
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 will continue to schedule regular pest treatment, and ensure that facility is treated for bed bugs as part of their treatment, as well as address client hygiene issues exacerbating the issue. Admin to ensure that all mattresses have mattress covers due to chronic bed bug infestation. Please submit POC to CCLD by POC due date.
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On 11/30/22, LPA observations of rooms #2 and #11, revealed and confirmed active bedbugs on the mattresses of two client beds. This poses a potential personal rights risk to client.
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***Civil Penalty issued on 11/30/22.***
Type B
12/16/2022
Section Cited
CCR
80087(a)
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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 requirement was not met as evidenced by:
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Administrator will ensure that the facility is clean and in good repair at all times.

Please submit POC to CCLD by POC due date.
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On 11/30/22, LPA observed the facility walls and floors were dirty throughout the entire facility, window sills were dirty in the client rooms and the kitchen, hole on the wall in the common/ TV room, unused furniture in the back yard (balcony - located outside of room #10) along with a lot of leaves and debris, bathrooms were not clean and the toilet in the bathroom located downstairs was broken and in disrepair, observed shower curtains to be dirty and in disrepair, bathroom sinks were dirty and water on the floor as well as toilets dirty. This poses a potential personal rights risk to client.
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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8