197603784-11-7-2023-28-AS-RORN-CXRMTF-20231120085329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603784
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:50:24 PM

Unsubstantiated

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
11/17/2022 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221117142151

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: 16	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Tompi Sihamau		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff do not assist resident with grooming.
Facility staff do not assist resident with personal hygiene.
Facility staff do not provide quality meals to residents.
Facility staff do not ensure facility is free of pests.
Facility staff do not clean facility as often as needed.
Facility does not have hot water.
Facility does not have smoke detectors.

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 Staff/ House Manager Tompi Sihamau and explained the purpose for the visit. Administrator Clarel Martine was unavailable during LPAs visit. LPA spoke to administrator on the phone.

The investigation consisted of: On 11/21/22, LPA Maldonado obtained a copy of the client and staff roster, conducted a tour of the physical plant with staff Tompi Sihamau. LPA also conducted interviews with C1-C6 and S1-S2 and requested copies of documents pertinent to the investigation. On 5/16/23, LPA requested and received copies of Staff and Client Rosters, Pest Control Maintenance invoice for January 2023 - April 2023, and Copy of menu for the last 30 days. LPA interviewed Staff 1-3 (S1-3) and Clients 7-13 (C7-13).

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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 4

Control Number 28-AS-20221117142151

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: 11/07/2023

NARRATIVE

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LPA Gonzalez additionally conducted a tour of the entire facility including client rooms, dining room, kitchen, TV room, facility bathrooms, outside common area, backyard, and outside storage area. The following client rooms were inspected: Room #1, #2, #5, #8, #10 and #11. On 11/07/23, LPA Gonzalez conducted a tour of the entire facility including client rooms, dining room, kitchen, TV room, facility bathrooms, outside common area, backyard, and outside storage area.

Investigation revealed the following: Regarding allegations, Facility staff do not assist resident with grooming and Facility staff do not assist resident with personal hygiene, it is alleged that facility staff do not assist residents with grooming and/ or personal hygiene as needed, and this has resulted in a boil developing on the back of a resident's head. Interviews conducted with Administrator Clarel and facility staff revealed that clients are encouraged to take a shower every day and are provided with 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 there are any clients that have boils on their head(s). 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. 7 out of 7 clients that were interviewed on 05/16/23 stated that they are provided with hygiene products when needed and that they do take showers. 3 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 7 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 allegation, Facility staff do not provide quality meals to residents, it is alleged that facility staff do not provide quality meals to residents. The residents are served hot dogs, and peanut butter and jelly sandwiches. Interviews conducted with 10 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. They stated that they are served hot dogs and peanut butter and jelly sandwiches at times

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20221117142151

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: 11/07/2023

NARRATIVE

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but not everyday. Administrator stated that food is ordered weekly to ensure that there is enough food in stock for client's daily dietary consumption and denied that clients are only served hot dogs and peanut butter and jelly sandwiches. LPA toured the facility kitchen and observed facility menu posted and observed an ample amount of food. There was enough food for 7-days nonperishables and 2-day perishables. LPA observed 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 allegation, Facility staff do not ensure facility is free of pests, it is alleged that facility staff do not ensure facility is free of pests. Rats, roaches, and bed bugs have allegedly been observed at the facility. Interview with Administrator Martine revealed that the facility does not have any rodents, roaches or bed bugs. He stated that in the past there was a problem with bed bugs but he has worked very hard to rectify that issue and there have been no bed bugs since 2022. He stated that he has not been notified by any clients or facility staff that they have seen any rodents, roaches or bed bugs in the facility. Administrator stated that the facility gets treated by pest control monthly. Interviews with staff revealed that there are no rodents, roaches or bed bugs in the facility and that the facility gets treated monthly. They stated that there have been no bed bugs for over one year. 12 of 13 clients interviewed stated that there are no rodents, roaches or bed bugs at the facility. 1 of 13 clients interviewed stated that they have seen bed bugs on roommates clothing that they bring from outside and that staff get rid of the bed bugs. 13 out of 13 clients stated that that the facility staff clean their rooms daily and laundry and linens are cleaned once a week. LPA Gonzalez conducted tours of a random selection of client rooms and did not see any evidence of roaches, bed bugs, rodents or any droppings indicating that there are roaches, bed bugs or 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 allegation, Facility staff do not clean facility as often as needed, it is alleged that facility staff do not clean facility as often as needed and the facility is dirty. LPA toured the facility today and did not observe that the facility was dirty. There are trash cans placed around the property for clients to use to throw their trash in. The dining tables and floors are wiped and clean. There are no obstructions to the passageways. LPA did not smell any urine nor unpleasant odor around the facility. Administrator and staff stated that the facility is cleaned on a daily basis and as needed. 13 of 13 clients interviewed stated that the facility staff clean their

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20221117142151

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: 11/07/2023

NARRATIVE

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rooms daily. LPA Gonzalez conducted a tour of the entire facility including 6 client rooms, dining room, kitchen, TV room, facility bathrooms, outside common area, backyard, and outside storage area and
observed the facility to be clean. LPA observed 1 staff cleaning the restrooms. 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 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 at the required temperature that is between 105 F - 120F. Interviews conducted with 13 out of 13 clients revealed that the facility always has hot water. 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 120F. 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 allegation, Facility does not have smoke detectors, it is alleged that the facility does not have smoke detectors. Interviews conducted with Administrator Clarel and facility staff revealed that the facility does have working smoke detectors. Administrator stated that he ensures that the batteries are switched out every three months to ensure that they are always in working order. 13 out of 13 clients stated that the smoke detectors in the facility work and stated that staff check that the batteries are working. LPA Gonzalez conducted a tour of the entire facility and observed and tested smoke detectors. LPA observed that all smoke detectors in the facility were working properly during the visits conducted on 05/16/23 and 11/07/23. Based on interviews conducted with facility staff, facility clients, and LPA observations, 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 Staff/ House Manager Tompi Sihamau.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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