198320393-2-19-2026-11-AS-SCIS-DSSUBA-20260403152602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320393
Report Date: 02/19/2026
Date Signed: 02/19/2026 10:14:31 AM

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
10/03/2025 and conducted by Evaluator Elvira Gonzalez

COMPLAINT CONTROL NUMBER: 11-AS-20251003144900

FACILITY NAME:	MANHATTAN PLACE		FACILITY NUMBER:	198320393
ADMINISTRATOR:	WATERS, LUTHER		FACILITY TYPE:	735
ADDRESS:	3939 SUTRO AVE		TELEPHONE:	(323) 491-6572
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90008
CAPACITY:	4	CENSUS: 3	DATE:	02/19/2026
		UNANNOUNCED	TIME BEGAN:	08:29 AM
MET WITH:	Kayla Butler		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Licensee did not prevent staff from physically abusing resident in care.
Licensee did not prevent a resident in care from physically abusing other resident in care.
Licensee did not ensure that resident's clothing needs were met while in care.
Licensee did not ensure that resident was provided with necessary hygiene products while in care.
Staff did not allow resident to buy food while in care.

INVESTIGATION FINDINGS:

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** This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 01/15/26. ** On 02/19/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint investigation visit for the allegations listed above. LPA met with staff, Kayla Butler, and explained the purpose of this visit is to provide an amended copy of the LIC9099 report.

On 01/15/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent visit to further investigate the above mentioned allegations and deliver findings. LPA met with Manager, Tyler Roach, and Administrator, Luther Waters, and the purpose of the visit was explained.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026

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 11-AS-20251003144900

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: MANHATTAN PLACE	FACILITY NUMBER: 198320393
	VISIT DATE: 02/19/2026

NARRATIVE

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The investigation consisted of the following: On 10/10/25, LPA requested the staff roster, and client roster. LPA reviewed service records for client #1 (C1) and requested copies of the following documents: Admission Agreement, Facesheet, Physician’s Report, Preplacement Appraisal Information, Functional Capability Assessment, Applied Behavioral Alternatives, Inc. Quarterly Progress Evaluation Report, South Central Los Angeles Regional Center My Individual Program Plan, South Central Los Angeles Regional Center Individual Program Plan, Quarterly Program Review (SCLARC) Review January 2025-March 2025, Record of Client’s Safeguarded Cash Resources, Unusual Incident/Injury Reports (dated: 01/02/25, 01/22/25, 01/25/25, 01/28/25, 02/17/25, 03/09/25). LPA conducted interviews with staff #1-#2 (S1-S2), and witness #1 (W1). Additionally, LPA and Tyler Roach conducted a tour of the entire facility. On 01/15/26, LPA Gonzalez conducted interviews with clients #2-#3 and attempted to interview clients #1 and #4.

The investigation revealed the following:

Allegation: Licensee did not prevent staff from physically abusing resident in care. It is being alleged that staff are hitting and assaulting C1. On 10/10/25, LPA Gonzalez conducted interviews with S1-S2. Of those interviewed, 2 out of 2 staff denied the allegation. Both S1 and S2 said that C1 is known for making false statements and making up stories and has made false accusations against staff.

On 01/15/26, LPA Gonzalez conducted interviews with C2-C3 and attempted to interview C1 but was unable to as C1 is no longer in the facility and staff did not have any contact information for C1. LPA attempted to interview C4 but was unable to as they were out of the facility in the community. Of those interviewed, 2 out of 2 clients could not corroborate with the allegation. 2 out of 2 clients said staff treat them with dignity and respect.
On 01/15/26, LPA Gonzalez conducted a review of the facility’s incident reports (August, September, October 2025). Incident reports did not show an incident involving C1 being physically abused by staff.

Based on the evidence gathered, interviews conducted, and records reviewed, 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 is unsubstantiated.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20251003144900

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: MANHATTAN PLACE	FACILITY NUMBER: 198320393
	VISIT DATE: 02/19/2026

NARRATIVE

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Allegation: Licensee did not prevent a resident in care from physically abusing other resident in care. It is being alleged that a client is being hit and assaulted by another client. On 10/10/25, LPA Gonzalez conducted interviews with S1-S2. Of those interviewed, 2 out of 2 staff denied the allegation.

On 01/15/26, LPA Gonzalez conducted interviews with C2-C3 and attempted to interview C1 but was unable to as C1 is no longer in the facility and staff did not have any contact information for C1. LPA attempted to interview C4 but was unable to as they were out of the facility in the community. Of those interviewed, 2 out of 2 clients denied the allegation.

On 01/15/26, LPA Gonzalez conducted a review of records and revealed the following: A review of the facility’s incident reports (August, September, October 2025) did not show an incident involving a client being physically assaulted by another client.

Based on the evidence gathered, interviews conducted, and records reviewed, 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 is unsubstantiated.

Allegation: Licensee did not ensure that resident's clothing needs were met while in care. It is being alleged that staff are not providing a client with clothes. On 10/10/25, LPA Gonzalez conducted interviews with S1-S2. Of those interviewed, 2 out of 2 staff denied the allegation. An interview conducted with S1 revealed that clients are provided with the necessary clothing and undergarments.

On 01/15/26, LPA Gonzalez conducted interviews with C2-C3 and attempted to interview C1 but was unable to as C1 is no longer in the facility and staff did not have any contact information for C1. LPA attempted to interview C4 but was unable to as they were out of the facility in the community. Of those interviewed, 2 out of 2 clients could not corroborate with the allegation. 2 out of 2 clients said they have enough clothing.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20251003144900

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: MANHATTAN PLACE	FACILITY NUMBER: 198320393
	VISIT DATE: 02/19/2026

NARRATIVE

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On 10/10/25, LPA and Tyler Roach toured the facility inside and out. LPA observed that all bedrooms and bathrooms were clean. All beds had the required linens and supplies. LPA observed the clients to have an ample supply of clothing in their closets and drawers, readily available for residents to change if needed.

Based on the evidence gathered, interviews conducted, and records reviewed, 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 is unsubstantiated.

Allegation: Licensee did not ensure that resident was provided with necessary hygiene products while in care. It is being alleged that staff are not providing a client with soap and shampoo. On 10/10/25, LPA Gonzalez conducted interviews with S1-S2. Of those interviewed, 2 out of 2 staff denied the allegation. An interview with S1 revealed that clients are provided with the necessary hygiene products needed.

On 01/15/26, LPA Gonzalez conducted interviews with C2-C3 and attempted to interview C1 but was unable to as C1 is no longer in the facility and staff did not have any contact information for C1. LPA attempted to interview C4 but was unable to as they were out of the facility in the community. Of those interviewed, 2 out of 2 clients could not corroborate with the allegation.

On 10/10/25, LPA and Tyler Roach toured the facility inside and out. LPA observed closet where hygiene products are stored and observed items such as hair shampoo, body soap, conditioner, toothpaste, mouthwash and Q Tips to name some items.
Based on the evidence gathered, interviews conducted, and records reviewed, 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 is unsubstantiated.

Allegation: Staff did not allow resident to buy food while in care. It is being alleged that a client was not allowed to buy food. On 10/10/25, LPA Gonzalez conducted interviews with S1-S2. Of those interviewed, 2 out of 2 staff denied the allegation.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20251003144900

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: MANHATTAN PLACE	FACILITY NUMBER: 198320393
	VISIT DATE: 02/19/2026

NARRATIVE

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On 01/15/26, LPA Gonzalez conducted interviews with C2-C3 and attempted to interview C1 but was unable to as C1 is no longer in the facility and staff did not have any contact information for C1. LPA attempted to interview C4 but was unable to as they were out of the facility in the community. Of those interviewed, 2 out of 2 clients could not corroborate with the allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, 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 is unsubstantiated.

No deficiencies were cited during this investigation.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026

LIC9099 (FAS) - (06/04)

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