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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 07/31/2025
Date Signed: 07/31/2025 03:40:28 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
07/28/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250728102808
FACILITY NAME:OLIVIA ISABEL MANORFACILITY NUMBER:
198601766
ADMINISTRATOR:KUNZ, ANAFACILITY TYPE:
735
ADDRESS:21515 S. FIGUEROA STREETTELEPHONE:
(310) 328-5116
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:110CENSUS: 83DATE:
07/31/2025
UNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Mata Fonopo & Ana KunzTIME COMPLETED:
02:59 PM
ALLEGATION(S):
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Staff dispose of resident’s belongings without authorized representative consent.
INVESTIGATION FINDINGS:
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On July 31, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent visit to gather information regarding the above allegation. LPA met with Mata Fonopo, Assistant Administrator and Ana Kunz Administrator, and explained the purpose of the visit. LPA was granted entry to the facility.

The investigation consisted of Interviews, collection of records and inspection of (C1's) room. Interviews were conducted with staff members #1 to #3 (S1-S3), client member #2 (C2) and witness members #1 to #2 (W1-W2). List of documents reviewed/obtained: Client Roster (dated 07/30/25), Employee Roster (dated 07/30/25), (C1)'s Client Personal Property and Valuables LIC 621 (4/13/23), Admissions Agreement and Identification and Emergency Information LIC 601 (dated 02/04/22), State of California License and Certificate of Marriage (dated 09/10/08) , and other records pertinent to this complaint.

(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
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-20250728102808
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: OLIVIA ISABEL MANOR
FACILITY NUMBER: 198601766
VISIT DATE: 07/31/2025
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff dispose of resident’s belongings without authorized representative consent.

The complaint details an allegation that facility staff disposed of clients' belongings without an authorized representative consent. Specifically, it has been reported that Client #1's (C1) collection of books, valued at approximately $1,000, was discarded under the instructions of Staff #1 (S1) without the consent of (C1's) authorized representative. Furthermore, it is noted that the holder of the power of attorney for (C1) was unaware of this action and would have preferred to donate the items instead. No further details were provided about this matter.

A review of Client #1's (C1) Admissions Agreement and Identification and Emergency Information LIC 601 indicates that (C1) was admitted to Olivia Isabel Manor on February 4, 2002. (C1) consistently resided at the facility until (C1's) passing on July 13, 2025.

On July 30, 2025, and July 31, 2025, between 10:05 AM and 04:15 PM, the Department interviewed the staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the three (3) staff members were unable to validate this claim. Staff members (S1 and S2) stated that Client #1's (C1) spouse and roommate, Client #2 (C2), placed some items outside the room following (C1's) passing on July 13, 2025. These personal belongings were obstructing the passageways, creating a fire hazard, and increasing the risk of theft and loss of valuable property when items are left exposed.

(S1 and S2) explained that they allowed (C2) to grieve the loss of (C1) without applying any pressure to make decisions regarding (C1's) personal property. They also noted that (C1) did not have an assigned power of attorney or conservator. Between July 21 and July 24, 2025, (S2) notified (C1's) family member who communicated via telecommunication messages and authorized the facility to take appropriate actions regarding the collection of books, including offering them for donation.

On July 23, 2025, Staff #3 (S3) reported that (C2) had instructed (S3) to dispose of (C1's) belongings, including several books. (S3) noted that a family member of (C2) was present and confirmed that (C2) had given authorization to dispose of the few selected items. (S3) expressed understanding towards (C2) and acknowledged that it's essential to have the opportunity to reconsider decisions. To facilitate this, an additional 48 hours have been provided for (C2) to decide on the disposal of the items.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250728102808
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: OLIVIA ISABEL MANOR
FACILITY NUMBER: 198601766
VISIT DATE: 07/31/2025
NARRATIVE
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During this time, (S3) asked (C2) to sign a Resident Report, dated (07/23/25), which granted full consent for the disposal of selected personal items.

On July 31, 2025, between 10:10 AM and 11:20 AM, the Department interviewed the witnesses identified as family members, Witness #1 and Witness #2 (W1-W2). Two (2) out of the two (2) witnesses involved, neither were able to corroborate the claim. Witness #1 (W1) confirmed that the facility had engaged in ongoing communication (W1) via telecommunication messaging. (W1) provided consent to discuss the prudent actions regarding specific personal belongings belonging to (C1). In contrast, Witness #2 (W2) recalled an incident on July 23, 2025, in which (C2) instructed the facility staff to dispose of particular items, including a valued collection of books.

Both (W1 and W2) emphasized that this situation stemmed from a substantial misunderstanding. They firmly stated that they did not hold the facility accountable, as their instructions were exclusively aimed at the disposal of (C1’s) items—an action thoroughly authorized by (C2), who has the legal authority to make such decisions as the spouse of (C1).

Following Client #1's (C1's) passing on July 13, 2025, an interview was not attainable.

A review of Client #1’s (C1) Personal Property Valuables LIC 621 (dated 04/13/23) listed items including DVDs, clothing, shoes, and appliances, but no books. After reviewing (C1’s) Admissions Agreement and Identification and Emergency Information LIC 601 (dated 02/04/02), it was noted that there was no mention of the power of attorney, conservator, or public guardian. Furthermore, an examination of the State of California License and Certificate of Marriage (dated 09/10/08) confirmed the marriage between (C1 and C2). Additionally, telecommunications records between facility staff and (C1’s) family member demonstrated that a representative was notified.

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

An exit interview was conducted with the Administrator Ana Kunz, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3