198601056-10-19-2023-11-AS-MVAO-CWWS4B-20231024133230

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601056
Report Date: 10/18/2023
Date Signed: 10/19/2023 10:55:39 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, 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
03/16/2023 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230316152533

FACILITY NAME:	NABAUNS MANOR, INC.		FACILITY NUMBER:	198601056
ADMINISTRATOR:	INGRID CHAMBERLAIN		FACILITY TYPE:	735
ADDRESS:	312 WEST 109TH STREET		TELEPHONE:	(323) 455-1581
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90061
CAPACITY:	6	CENSUS: 3	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Staff #1: Odessie Bryant, Caregiver)		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility staff was not present at the facility to let resident in, on more than one occasion.
Facility staff did not ensure that resident had access to a restroom at the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Odessie Bryant) as Administrator (A1: Ingrid Chamberlain) was unavailable at the time of this visit. LPA/RA conducted a risk assessment prior to entering facility. Staff #1 informed LPA/RA that the facility has no COVID cases nor do the clients or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation(s).

An initial 10-Day visit was conducted by LPA Martessa Brown on (03/23/23) who was met by Administrator. During today's visit, LPA/RA Ceniceros re-interviewed Administrator (via telephone), Staff #1(S1), Client #2 and Client #3 (C2, C3) between 8:15 am - 9:00 am (via telephone). LPA Brown and RA Ceniceros did not interview Client #1 due to the client's relocation on 11/15/22 by the South Central Los Angeles Regional Center's (SCLARC) to another facility. Client #4 was not interviewed by LPA/RA as the Consumer was out on an outing in the community with their adult day program (Grace Care). LPA/RA interviewed Client #1's

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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 11-AS-20230316152533

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: NABAUNS MANOR, INC.	FACILITY NUMBER: 198601056
	VISIT DATE: 10/18/2023

NARRATIVE

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former SCLARC Service Coordinator (Witness #1) via telephone. LPA/RA called Witness #2 (W2: "New" SCLARC Service Coordinator) in an attempt to interview, but W2 was unavailable. LPA toured (between 9:30 a.m. - 9:45 a.m.) the facility’s physical plant for health and safety purposes of clients in care. LPA/RA reviewed (between 10:00 a.m. - 10:30 a.m.) the Admission Agreement (dated 10/25/22), IPP Planning Meeting/Review Agreement (dated 10/25/22), Caregivers Daily Activity Log (from 10/30/22 thru 11/09/22), Personal Rights, House Rules, and the Staff & Client rosters.

Regarding Allegation #1: this investigation revealed that Client #1 was placed at the facility by the South Central Los Angeles Regional Center (SCLARC) as an out-of-home respite (temporary) placement for (approximately) 21 days. Client #1 was ambulatory and would come and go from the facility into the community and/or work. On several occasions, Client #1 would wake up in the early morning hours (approximately 5:00 a.m.) and leave - only to return to the facility in the evening (approximately 6:00 p.m.) On this occasion, Client #1 would refuse breakfast or to take a lunch and refused dinner. Client #1 had gone out at 5:00 a.m. and it was raining that day. Staff #1 was the caregiver at the facility when Client #1 returned at 6:00 p.m. [A review of the facility's Caregivers Daily Activity Log (from 10/30/22 thru 11/09/22) was reviewed and documented the incident; of which, a staff member was at the facility upon Client #1's arrival to the facility on more than one occasion on the dates in question: 11/07/22, 11/09/22, and week of 10/30/22. Interviews conducted of facility staff corroborated that the facility at all times has a staff member at the facility whenever the clients arrive to their facility. Interviews conducted of the clients corroborated that facility staff are always present upon their arrival to the facility. Interview conducted of Witness #1 corroborated that the facility is not found at fault and that a facility staff member is present at the facility whenever a client arrives to their facility.

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 of PERSONAL RIGHTS: Facility staff was not present at the facility to let resident in, on more than one occasion is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based upon interviews conducted of facility staff corroborated the clients have access to the restrooms at all times. The facility has 3-bedrooms and 1-bath. Client #1 would wake up (approximately 4:30 a.m.) and use the restroom and leave the facility by 5:00 a.m. Client #2 would wake up (approximately 5:00 a.m.) and use the restroom to get ready for ADP. Client #3 would wake up (approximately 5:00 a.m.) and use the restroom to get ready for work. Client #4 would

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20230316152533

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: NABAUNS MANOR, INC.	FACILITY NUMBER: 198601056
	VISIT DATE: 10/18/2023

NARRATIVE

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wake up (approximately 4:30 a.m.) and use the restroom to get ready for adult day program (Pathways). The facility is an all female facility which allowed the clients to have access to the restroom. If the restroom was unavailable then once it became available, the clients had access at all times. Facility staff did not receive a complaint from either of the clients regarding the allegation. Interviews conducted of clients corroborated that staff ensured that the clients had access to the restroom at all times. Interview conducted of witness (via telephone), corroborated that the facility is not at fault for the allegation made by Client #1.

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 of PERSONAL RIGHTS: Facility staff did not ensure that resident had access to a restroom at the facility is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Staff #1.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

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