198320092-5-29-2024-11-AS-UCOL-D66UAC-20240612152433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320092
Report Date: 05/29/2024
Date Signed: 05/29/2024 05:49:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2024 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240521110815

FACILITY NAME:	LIFESTYLE BOARD AND CARE		FACILITY NUMBER:	198320092
ADMINISTRATOR:	MANOR, KIM		FACILITY TYPE:	735
ADDRESS:	149 EAST 235TH STREET		TELEPHONE:	(562) 743-1037
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 6	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	08:47 AM
MET WITH:	Kim Manor, Administrator		TIME COMPLETED:	06:03 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff discriminated against resident
Staff did not provide adequate food service
Staff did not treat resident with dignity and respect
Staff withheld resident’s check

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 05/29/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Kim Manor, Administrator (S1) and the purpose of the visit was explained. S1 and LPA toured the facility.

The investigation consisted of the following:
On 05/29/24 LPA requested and reviewed facility, staff and resident documents, one (1) declaration form from S1 and LPA and S1 toured the facility. LPA interviewed four (4) out of six (6) residents and 1 out of eleven (11) staff.
The investigation revealed the following:
Regarding the allegation “Staff discriminated against resident”, it has been alleged that staff treat residents unpleasantly, requiring residents to use the side door to the staff’s office.
Interviews revealed that 1 out of 1 staff and three (3) out of 4 residents have denied the allegation.
Report continues, see LIC9099C.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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 3

Control Number 11-AS-20240521110815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LIFESTYLE BOARD AND CARE	FACILITY NUMBER: 198320092
	VISIT DATE: 05/29/2024

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

Record reviews revealed that directly under "Name of Resident", on Admissions Agreement, there is a quote stating the following, "There are no restrictions with regard to Race, Color, Gender, Religion, National Origin or Ancestry." LPA observed two (2) signs on the office door, quoted as, "Please use the back door". LPA obtained a declaration form from S1, noting that the facility hosts three (3) African-Americans, two (2) Asian(s) and one (1) Caucasian resident(s) and that the facility is a racially mixed facility.
Based on LPA observations, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
Regarding the allegation “Staff did not provide adequate food service”, it has been alleged that staff treat residents negatively, related to the food that’s been prepared by resident(s).
Interviews revealed that 1 out of 1 staff and 2 out of 4 residents have denied the allegation. Record reviews revealed that the house rules of the above-mentioned facility include "Do not use stove without asking staff" LPA obtained a declaration form from S1, noting that the facility requires resident(s) to notify the staff prior to usage of the cooking appliances, to ensure safety measures within the facility.
Based on LPA observations, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
Regarding the allegation “Staff did not treat resident with dignity and respect”, it has been alleged that staff refuse to speak to resident(s) and that staff make fun of resident(s) lifestyle.
LPA observed S1 constantly assisting with residents, incoming telephone calls, 1 Dr. visit and 1 prospective resident tour while LPA was on-site. Interviews revealed that 1 out of 1 staff and 2 out of 4 residents have denied the allegation. Record reviews revealed that the facility staff will conduct one-on-one, hands-on, training regarding activities of daily living which includes conducting personal laundry services. Record reviews revealed that directly under "Name of Resident", on Admissions Agreement, there is a quote stating the following, "There are no restrictions with regard to Race, Color, Gender, Religion, National Origin or Ancestry."LPA obtained a declaration form from S1, noting that the facility respects resident(s) personal needs, which is always delivered with dignity and with a generous level of care.

Report Continues, see LIC9099C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20240521110815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LIFESTYLE BOARD AND CARE	FACILITY NUMBER: 198320092
	VISIT DATE: 05/29/2024

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 LPA observations, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated
Regarding the allegation “Staff withheld resident’s check”, it has been alleged that residents have had to wait two weeks to acquire their monies from the staff.
Interviews revealed that 1 out of 1 staff and 2 out of 4 residents have denied the allegation. Record reviews revealed that 1 resident (R1) obtained four-hundred dollars ($400) on 05/13/24. R1's Public Guardian funds had been delivered to the above-mentioned facility on 05/28/24 and S1 deposited those funds on 05/28/24. S1 has stated that the funds will be available on 05/30/24.
Based on LPA's record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

An exit interview was conducted with Kim Manor, Administrator (S1), and a copy of this report has been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3