197606540-2-9-2024-28-AS-LHIS-D2DPLV-20240212102521

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606540
Report Date: 02/09/2024
Date Signed: 02/09/2024 09:52:29 AM

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:	02/09/2024
		UNANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	John Michael Tanada		TIME COMPLETED:	09:59 AM

ALLEGATION(S):

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Licensee is not addressing leaking ceiling

INVESTIGATION FINDINGS:

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***This report supersedes report dated 02/02/2024, it was done to correct some information and nothing else has changed and the findings remain the same****

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.
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 second servings during breakfast, lunch or dinner.

(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: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

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-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: 02/09/2024

NARRATIVE

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The investigation revealed: LPA took tour of entire facility with Administrator and noticed room #2 #8 and #21 had water damage on the ceiling. One room had a bucket to collect water and it had about 2 inches of water in the bucket. The floor was also covered with wet bed pads to absorb the leakage. LPA interviewed 4 staff and 3 of 4 staff denied the allegation, and 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.

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

Based on LPA observations during tour of facility with Administrator, 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: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC9099 (FAS) - (06/04)

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