198601766-11-19-2021-11-AS-EMAZ-C9WPRZ-20211221103333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 11/17/2021
Date Signed: 11/19/2021 10:11:15 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2021 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211020092518

FACILITY NAME:	OLIVIA ISABEL MANOR		FACILITY NUMBER:	198601766
ADMINISTRATOR:	KUNZ, ANA		FACILITY TYPE:	735
ADDRESS:	21515 S. FIGUEROA STREET		TELEPHONE:	(310) 328-5116
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	110	CENSUS: 91	DATE:	11/17/2021
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Ana Kunz		TIME COMPLETED:	09:48 AM

ALLEGATION(S):

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Resident(s) physically assaulted while in care.
Resident(s) sexually assaulted while in care.
Staff speak inappropriately to resident in care.

INVESTIGATION FINDINGS:

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On 11/17/21, Licensing Program Analysts (LPAs) Ernand Dabuet and Gail Johnson conducted a subsequent unannounced complaint visit at this facility, LPA was greeted by assistant administrator Mata Fonopo.
LPA explained the purpose of today's visit was to gather information on the allegations above. The administrator Ana Kunz was made aware of the visit and was able to join the team at a later time.

The investigation consisted of the following: An interview was conducted with six (3) staff and (12) clients. A review of the current staff and resident roster and client #1 (C1),(C2),(C3), and (C4) service records and other pertinent records were reviewed. A tour of the physical plant was conducted on 10/21/21, 11/09/ 21, and 11/17/21.

Evaluation Report continues LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

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-20211020092518

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: OLIVIA ISABEL MANOR	FACILITY NUMBER: 198601766
	VISIT DATE: 11/17/2021

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident(s) physically assaulted while in care.

The detail on the allegation states client #1 (C1) was physically assaulted. The complainant reports (C1) was physically assaulted while standing in the medication line by a male client. (C1) claims the male client took his cane and struck (C1) across her back for no reason.
During the interview with (C1), she expressed she was uncertain of the male suspect’s name or race. (C1) was uncertain about the date the incident happened. (C1) claims she was hit on her back and it left marks that lasted a few hours. (C1) reports there is no fractured and she did not require medical attention. (C1) mentioned two (2) clients were present during the incident as witnesses. The Department interviewed both client #11-#12 (C11-C12) both were present during the incident and denies having witnessed any physical assault taking place with (C1). The management at this facility conducted an internal investigation and interviewed staff members and clients who were present during the incident on 10/04/21. The clients and staff had written statements stating they were unable to corroborate (C1)’s accusation and that no security camera footage was captured. The Los Angeles County Sherriff’s investigated and interviewed (C1) along with (C11-C12) and found no evidence to support this allegation of physical assault. The Department interviewed staff #1-#3 (S1-S3) and client #2-#10 all verified that they had no knowledge of any physical assault taking place on 10/04/21. Furthermore, (S1) examined (C1)’s back where she claims she was struck and found on mark or bruises. During (C1)’s interview, she recalled back during Christmas Eve 2004 she was struck in the right eye client #4 (C4).
(C1) states she did not notify management at the time and did not seek medical attention. (C4) denies this accusation and states this is false. Client #2 (C2) who is related to (C1) and has shared a room for 20 years, states he is unaware of such assault in 2004. An interview with a family member of (C1) witness #1 (W1) states no assault had taken place and that this accusation is false. According to (W1), (C1) is unhappy in her current living situation and may perceive things that are not really happening. Based on the Department’s observation, interviews, and a review of service records that were conducted, the Department found there is no evidence to support the allegation mentioned above.

Evaluation Report Continues on LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 11-AS-20211020092518

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: OLIVIA ISABEL MANOR	FACILITY NUMBER: 198601766
	VISIT DATE: 11/17/2021

NARRATIVE

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Allegation: Resident(s) sexually assaulted while in care.
It is alleged that clients at this facility are sexually assaulted while in care. The complainant states clients are sexually assaulted in the facility by other clients. The complainant was not able to provide any specific events. An interview with (C1) confirmed that she is not sexually assaulted. (C1) states information received was from other people and cannot be for certain if there is any truth – it is all “hearsay”. The Department interviewed staff #1-#3 (S1-S3) and client #2-#12 (C2- C12) all verified that they had no knowledge of any sexual assaults taken at this facility. According to (C2-C12) they all find Olivia Isabel Manor to be a safe place to live and had no concerns for their safety. The Los Angeles County Sherriff’s investigated and interviewed (C1) and found no evidence to support this allegation of the client's sexual assault at this facility. Based on the Department’s observation, interviews, and a review of service records that were conducted, the Department found there is no evidence to corroborate the allegation mentioned above.

Allegation: Staff speaks inappropriately to residents in care.
It is alleged that staff speaks inappropriately to clients in care. The complainant claims the staff is very assertive and that clients do what they need to do to feel included or accepted. According to (C1), staff #3 (S3) is aggressive and yells at a resident in care. (C1) claims (S3) does not treat her or other clients with dignity. (C1) recalls an incident with (S3) when she must obtain her medications she is yelled at a mocked for no reason. (C1) claims that (S3) yells through the intercom to gather the clients and does not appreciate her tone. An interview with (S3) claims this is untrue and denies this accusation. (S3) states that they have over 90 clients living at this facility that requires their medications. There is a system where they all must line up six (6) feet apart first-come-first-served bases. (C1) would often cut in line and redirected to go back of the line. (C1) considers action as being assertive or rude when told what to do or follow house rules. (S3) claims she never uses the tone of her voice to intimate or disrespects the clients in care. Interviews conducted with clients #3-#12 (C3-C12) all claim that (S3) along with the other staff treat them with dignity and respect. Based on the Department’s observation, interviews, and a review of service records that were conducted, the Department found there is no evidence to support the allegation mentioned above.

Evaluation Report Continues on LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20211020092518

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: OLIVIA ISABEL MANOR	FACILITY NUMBER: 198601766
	VISIT DATE: 11/17/2021

NARRATIVE

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The Department’s investigation consisted of an inspection of the facility, observation, review of (C1’s) service records, incident report, and other pertinent documents relevant to this case, interviews conducted and found no evidence to support the allegations mentioned above.

Based on the information gathered, there is no evidence to support the allegations: Resident(s) physically assaulted while in care, Resident(s) sexually assaulted while in care, Staff speaks inappropriately to resident in care.

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.

No Deficiencies cited under California Code of Regulations Title 22.

An exit interview was conducted with Ana Kunz and a copy of the report was provided by email. review of service records that were conducted, the Department found there is no evidence to support the allegation mentioned above.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4