198320092-5-1-2023-11-AS-JHAD-CT2LAV-20230622083547

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320092
Report Date: 05/01/2023
Date Signed: 05/01/2023 06:39:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/24/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230424141427

FACILITY NAME:	LIFESTYLE BOARD AND CARE		FACILITY NUMBER:	198320092
ADMINISTRATOR:	ANGELES, JENNYLYN		FACILITY TYPE:	735
ADDRESS:	149 EAST 235TH STREET		TELEPHONE:	(562) 743-1037
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 5	DATE:	05/01/2023
		UNANNOUNCED	TIME BEGAN:	08:48 AM
MET WITH:	Kim Manor		TIME COMPLETED:	04:47 PM

ALLEGATION(S):

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Staff threatens resident.
Staff yells at residents.
Staff not keeping facility free from pests.
Staff is not providing adequate food service to residents.

INVESTIGATION FINDINGS:

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On 05/01/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by administrator Kim Manor. LPA explained the purpose of today's visit is to investigate the allegations mentioned above.

The investigation consisted of the following: An interview with staff #1 (S1), client #1-#6 (C1-C6), and witnesses #1-#2 (W1-W2) about the allegations mentioned above. Service record was obtained for (C1) and other documents in association with this complaint. A tour of the facility was conducted.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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 11-AS-20230424141427

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LIFESTYLE BOARD AND CARE	FACILITY NUMBER: 198320092
	VISIT DATE: 05/01/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff threatens resident.
Staff yells at residents.
It is alleged staff #1 (S1) had yelled and threatened (C1) while a client at this facility. According to the complainant, (S1) has threatened and emotionally harassed (C1). The complainant was unable to provide further details on the matter such as the day, date, time, or witnesses involved. An interview with (C1) stated she liked living at the facility and it was “okay”. (C1) stated there were just too many house chores, rules, and restrictions. (C1) did claim not to have been threatened by (S1). (C1) did clarify that perhaps it may be a language or cultural barrier for (S1). (C1) stated she did not think (S1) was disrespectful but felt (S1) did imply strictness when it comes to rules. (C1) stated she was preoccupied with her Kindle for activities and will often have earbuds activated to preoccupy time. An interview with (S1) denies this allegation and stated she treats all clients with dignity and respect. (S1) stated (C1) is not one to want to follow any house rules and will reluctantly volunteer to do any house chores. (S1) stated she has never threatened (C1) with the statement “I’m going to kick you out”. (S1) confirmed that (C1) is constantly abstracted with earbuds that she must speak at a great volume to get (C1’s) attention. (S1) stated perhaps (C1) found the action to be assertive or rude. Interviews conducted with clients #2-#6 (C2-C6) revealed (S1) has a good relationship with the clients. They all asserted that (S1) treated them with dignity and respect and were complimentary of (S1). (C2-C6) did not have concerns for their health or safety at living at this facility. An interview with (C1) social worker witness #2 (W2) reported having no personal rights issues with (C1) living at this facility. Based on information gathered, the Department found there is no evidence to support the allegations mentioned above.
Allegation: Staff not keeping facility free from pests.
Details of the complaint state the facility has pests. The complainant reported the facility had pest problems with cockroaches in January, February, and March 2023 in the kitchen and laundry area. The complainant did not observe these pest problems only through conversation with client #1 (C1). An interview with (C1) reported pest issues were apparent in January when (C1) first moved into the facility and signs of cock- roaches were in the kitchen. (C1) was unsure what the facility did to mitigate the problem. (C1) reported not seeing any other occurrences after January 2023. (S1) denies this allegation.
(Evaluation Report continues LIC 9099-C)
This report serves as an amendment to clarify findings. It does not supersedes the complaint investigation findings reflected on report created 05/01/23.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20230424141427

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LIFESTYLE BOARD AND CARE	FACILITY NUMBER: 198320092
	VISIT DATE: 05/01/2023

NARRATIVE

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(S1) stated there has been no history of pest issues. (S1) stated the facility is proactive and has a contract agreement with a reputable pest control company.

The Department observed the facility to be clean and maintained in order during the initial visit on 05/01/23, The Department observed (C1’s) room, kitchen, and laundry area appeared to be maintained for cleanliness with no pest activity. An interview with staff #1 (S1) expressed the staff continues to ensure that the facility is in healthful conditions due to COVID-19 and extra work has been arranged by the administrator to keep this facility in a safe and sanitary environment for everyone Interview with the client #2-#6 (C2-C6) reported this facility is clean and sanitary. There is no sign of pests inside this group home. (C5-C6) expressed this facility prides on cleanliness. An interview with social worker witness #2 (W2) reported having no issues with pests at this facility and did not observed any during any of the visits. Based on information gathered, the Department found there is no evidence to support the allegation.

Allegation: Staff is not providing adequate food service to residents.
The details of the complaint reported the staff does not provide adequate food to clients in care. The complainant reported this facility does not have enough food for clients. The Department conducted an inspection visit on 05/01/23 and observed the facility is following Title 22 Section 80076 Food Services. The Department observed food supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. The food supply included milk products, meat, vegetables, fruits, bread, cereals, juices, and sweets. A weekly menu was posted and made available for review for residents. Moreover, the facility had an emergency food supply in kitchen cabinets. An interview with client #1 (C1) confirmed the facility provided three (3) meals and snacks daily. (C1) was uncertain if the facility offered second servings as (C1) has never inquired. Interviews with the clients #2-#6 (C2-C6) all confirmed the facility serves three meals daily with snacks and had no concerns with the facility not having the variety or enough food supply. (C5-C6) both confirmed that second servings are offered upon request.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230424141427

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LIFESTYLE BOARD AND CARE	FACILITY NUMBER: 198320092
	VISIT DATE: 05/01/2023

NARRATIVE

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An interview with (C1) social worker witness #2 (W2) was unable to corroborate this allegation. According to (S1) groceries are restocked on a daily basis. Based on the gathered information, the allegation mentioned above cannot be supported.

Based on observation, record analysis, and interviews, there is no evidence to support the allegations to support the allegations mentioned above.

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 conducted with Kim Manor and copy of the report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

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