197606540-9-28-2021-28-AS-CYEE-C8M5Q5-20211109190859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606540
Report Date: 09/27/2021
Date Signed: 09/28/2021 07:23:00 AM

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
08/04/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210804162048

FACILITY NAME:	LA VERNE MANOR		FACILITY NUMBER:	197606540
ADMINISTRATOR:	JOHN MICHAEL TANADA		FACILITY TYPE:	740
ADDRESS:	2555 6TH STREET		TELEPHONE:	(909) 593-4567
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	80	CENSUS: 36	DATE:	09/27/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	John Michael Tanada, administrator		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Residents are locked in their rooms.
Facility is not clean.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegations listed above. LPA Spencer met with administrator John Michael Tanada and explained the purpose of today's visit.

The investigation consisted of the following: During the initial visit on 8/13/21, LPA Spencer took a tour of the facility and interviewed the administrator, staff #1-2 (S1-S2), and residents #1-5 (R1-R5). LPA obtained a copy of the staff roster, resident roster, and house rules. During today's subsequent visit, LPA Spencer interviewed residents #6-9 (R6-R9), the administrator, and reviewed camera footage and thermostats.

The investigation revealed the following: Regarding the allegation, "residents are locked in their rooms," it was alleged that residents are required to stay in their rooms after 5 p.m. 9 out of 9 residents interviewed stated that they usually go in their room around 8 p.m. for bedtime but they are not forced and are allowed to leave their room anytime. ***Continued on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

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 5

Control Number 28-AS-20210804162048

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: LA VERNE MANOR	FACILITY NUMBER: 197606540
	VISIT DATE: 09/27/2021

NARRATIVE

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Interviews with staff indicated that residents are never locked in their rooms but most residents go to bed between 7-8 p.m. Staff stated that common areas such as the TV room are closed at 8 p.m. to keep noise levels down, but residents can leave their room at night at anytime. In a follow-up interview with the administrator, the administrator stated that during the COVID-19 shutdown they limited outings and group activities, however, residents were never locked in their rooms and can leave the facility freely as long once they sign out and are screened. A review of the house rules indicates that residents must sign in and out before leaving the facility. The house rules also indicate that noise levels should be kept to a minimum between 8 p.m.-7 a.m. On today's visit, LPA also observed residents outside of their rooms after 5 p.m. LPA reviewed camera footage showing that residents were able to walk in the halls, common areas, and leave the facility after 5 p.m.

Regarding the allegation, "Facility is not clean," LPA observed during both visits that the facility appeared clean and well-kept. 8 out of 9 residents stated that the facility is always clean and they are satisfied with the cleanliness of the facility. Interviews with all staff indicate that the facility is cleaned several times per day and staff have not heard of residents complaining about cleanliness. A review of the house rules states that "residents will do their part to keep their rooms clean and orderly."

Based on observation, interviews, and records reviewed, the findings indicate that 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.

An exit interview was conducted and a copy of this report was provided to the administrator via email.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
08/04/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210804162048

FACILITY NAME:	LA VERNE MANOR		FACILITY NUMBER:	197606540
ADMINISTRATOR:	JOHN MICHAEL TANADA		FACILITY TYPE:	740
ADDRESS:	2555 6TH STREET		TELEPHONE:	(909) 593-4567
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	80	CENSUS: 36	DATE:	09/27/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	John Michael Tanada, administrator		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Facility indoor temperature is too hot

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegation listed above. LPA Spencer met with administrator John Michael Tanada and explained the purpose of today's visit.

The investigation consisted of the following: During the initial visit on 8/13/21, LPA Spencer took a tour of the facility and interviewed the administrator, staff #1-2 (S1-S2), and residents #1-5 (R1-R5). LPA obtained a copy of the staff roster, resident roster, and house rules. During today's subsequent visit, LPA Spencer interviewed residents #6-9 (R6-R9), the administrator, and reviewed camera footage and thermostats.

***Continued on LIC9099C.***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20210804162048

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: LA VERNE MANOR	FACILITY NUMBER: 197606540
	VISIT DATE: 09/27/2021

NARRATIVE

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The investigation revealed the following: regarding the allegation, "facility indoor temperature is too hot," LPA observed that the facility had six (6) central thermostats. During the initial visit on 8/13/21 (9 a.m.- 1 p.m.), the indoor temperature read between 79-83 degrees F. LPA observed that the facility indoor temperature felt too hot. On today's visit during a cooler time of day (3 p.m.-6 p.m.), indoor temperature read between 72-79 degrees F and LPA observed that temperature did not feel too hot. Five (5) out of nine (9) residents interviewed stated that the indoor temperature gets too hot, while four (4) out of nine (9) residents stated that the indoor temperature is comfortable. S1-S2 stated that the indoor temperature gets too hot, and one staff stated that they have heard of residents complain about the indoor temperature. The administrator stated that the thermostats automatically turns on at 10 a.m. and/or once the indoor temperature reaches 80 degrees. The administrator stated that some residents have complained about the temperature being too hot, but the facility supplements the A/C with fans.

Based on observation and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the administrator via email along with the Appeals Rights.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20210804162048

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: LA VERNE MANOR	FACILITY NUMBER: 197606540
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/08/2021 Section Cited CCR 87303(b)	1 2 3 4 5 6 7	87303(b) Maintenance and Operation: A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidenced by...	1 2 3 4 5 6 7	The administrator stated that the facility will create a policy to include offering fans to residents upon request and adjusting thermostats to cooler temperatures during hottest times of the day. Administrator will send a copy of policy and send pictures of thermostats to CCL by POC due date.
	8 9 10 11 12 13 14	Based on observation and interviews, the licensee did not comply with the above section due to indoor temperature being too hot for 5 out of 9 residents interviewed. This poses a potential health, safety, or personal rights risk to persons 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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5