197606540-2-2-2024-28-AS-LHIS-D2DPLW-20240212102521

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606540
Report Date: 02/02/2024
Date Signed: 02/02/2024 02:12:57 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
01/30/2024 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240130125333

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: 41	DATE:	02/02/2024
		UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	John Micheal Tanada, Administrator		TIME COMPLETED:	02:27 PM

ALLEGATION(S):

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Licensee is not addressing leaking ceiling

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lopez conducted a complaint visit to investigate the above allegation. LPA met with Administrator, Michael Tanada and explained the reason for the visit.

LPA interviewed 4 Staff S#1-S#4 and 5 residents R#1-R#5 and reviewed and obtained residents and staff rosters, food menu and documentation indicating residents who are provided seconds during breakfast, lunch or dinner.

The investigation revealed. LPA took tour of entire facility with Administrator and noticed room #2 #8 and #21 with water damage on the ceilings. One room had a bucket to collect water and it had about 2 inches of water in bucket. The floor was also covered with wet bed pads to absorb the leaking. LPA interviewed 4 staff and all 3 of 4 staff denied the allegation, One staff stated that there was a small leak in the kitchen but has been fixed. LPA did not observe any leaks in the kitchen but there was some damage to the ceiling and administrator stated maintenance man and himself are repairing it. (Continued on 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

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

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
01/30/2024 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240130125333

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: 41	DATE:	02/02/2024
		UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	John Micheal Tanada, Administrator		TIME COMPLETED:	02:27 PM

ALLEGATION(S):

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Facility staff are not providing adequate food service to residents

INVESTIGATION FINDINGS:

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The investigation revealed:
Allegation: Facility staff are not providing adequate food service to residents. It is alleged that one resident is not getting adequate food service.

LPA obtained copy of menu and documentation of residents who are served seconds on any given day. LPA observed there to be enough 2 day perishable and 7 day non perishable food at the facility. LPA interviewed 4 staff and 4 of 4 staff denied the allegation. Some staff stated they make sure everyone eats and they even provide seconds. LPA interviewed 5 residents and 5 of 5 resident could not collaborate the allegation. All 5 residents stated they get enough to eat and are able to get seconds if they want to.

(Continued on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

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-20240130125333

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: LA VERNE MANOR	FACILITY NUMBER: 197606540
	VISIT DATE: 02/02/2024

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on observation, interviews, and records reviewed, the findings indicate that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the administrator.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20240130125333

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: LA VERNE MANOR	FACILITY NUMBER: 197606540
	VISIT DATE: 02/02/2024

NARRATIVE

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LPA interviewed 5 residents and 5/5 could not collaborate the allegations and all 5 stated that their rooms do not have a leak. LPA did not observe any of the rooms that were occupied to have leaks.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. Per California Code of Regulations, Title 22 the deficiencies issued were documented on LIC 9099D.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20240130125333

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: LA VERNE MANOR	FACILITY NUMBER: 197606540
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/02/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/02/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will repair the 3 rooms and send proof to LPA by POC date in form of photos, and invoices of the 3 rooms. Civil penalties for $1000 issued for repeat violation.
	8 9 10 11 12 13 14	LPA and Administrator observed rooms #2, #8 and #21 with severe water damage on the ceiling and a water bucket in one room to collect leaking water as well as wet bed pads spread out on the floor to absorbed the excess water which poses/posed a health and safety 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

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