198601766-11-20-2021-11-AS-EMAZ-C9WUYS-20211221150024

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 11/17/2021
Date Signed: 11/20/2021 10:47:45 AM

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
11/05/2021 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211105114419

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:	09:49 AM
MET WITH:	ANA KUNZ		TIME COMPLETED:	03:59 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents are allowed to smoke in their rooms.
Facility has bed bugs.
Facility is not kept clean.
Staff do not treat residents with dignity.
Staff yells at residents in care.
Resident was not assisted with their medication in a timely manner

INVESTIGATION FINDINGS:

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

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 (6) staff and (10) clients. A review of the current staff and resident roster and client #1 (C1's) service records and other pertinent records was reviewed. A tour of the physical plant was conducted on 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-20211105114419

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

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

INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Residents are allowed to smoke in their rooms.
It is alleged the clients are allowed to smoke in their rooms. According to the complainant, the facility allows the clients to smoke inside their rooms. An interview was conducted with (C1) claims she is not a smoker and states that clients are smoking inside their rooms. (C1) claims she has not observed any clients smoke in their rooms only that she has heard or smelled of smoke in the facility. (C1) is aware that clients are allowed to smoke and have a designated area outside the facility to smoke. Interviews were conducted with (C2-C10) all reported that they have not observed any clients smoke inside the facility or inside their own rooms. (C2-C10) all verified that smoking is allowed in designated areas as the courtyard patio and the back of the building in accordance with the facility house rules. An interview with staff #1-#6 (S1-S6) states there have has some incidents in the past, however, it has never gone unnoticed as they are proactive and have given written warnings in the past. (S1-S6) all reported that have had no recent activities where they have had to give out any warnings. (S1-S6) reported that all the clients are aware that smoking is not allowed indoors and enforced through their house rules. (S1) states that (C1) has been offered multiple times to move rooms to be far away from the designated smoking, however, chooses not to do so. According to (C1) she has lived in the same room for 20 years and should not have to sacrifice her well-being for others. 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.

Allegation: Facility has bed bugs & Facility is not kept clean.
Details of the complaint state the facility have bed bugs and that the facility is not kept clean due to staff shortage. According to the complainant (C1) has bed bugs in her room and has sustained bite marks. An interview with (C1) states begs bugs are in her room and have been bitten. The Department requested for (C1) to reveal the bite marks and did not observe any marks on arms and legs. An interview with (C2) who shares a room with (C1) states bed bugs were present in the tub area of the bathroom. The Department inspected rooms #108 and #105 and did not observe any beg bug activities on 11/09/21. Interviews with client #3-10 (C3-C10) all verified that they have not experienced bed bugs in their rooms or elsewhere in the facility.C3-C10) reports the management staff ensures that this issue is addressed monthly with a service agreement with Dewey Pest Control. Interviews with staff #1-#6 (S1-S6) reported a specific bed bug service agreement is contracted with Dewey Pest Control. Service is done routinely on a monthly basis or

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-20211105114419

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

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

as required or as requested. (S2) states the facility has had a history of bed bugs for the past 2-3 years. However, the management staff is proactive to ensure this matter is eradicated by replacing old furnishings and fumigating as required. The Department in past six (6) visits has conducted plant inspections at this facility. The LPA observed the facility to be clean and maintained in order. During the initial visit on 11/09/21 and 11/17/21, LPA observed (C1’s) room appears maintained for cleanliness. An interview with (C1) confirms that her room is cleaned daily. LPA has regularly observed housekeeping services being performed in prior inspections. In an interview with staff #1-#6 (S1-S6) all have expressed that they continue to ensure that the facility is in healthful conditions due to COVID-19 and extra work has been arranged by management and housekeeping staff to keep this facility in a safe and sanitary environment for everyone. 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 allegations.

Allegation: Staff yells at residents in care & Staff do not treat residents with dignity.
It is alleged staff #3 (S3) had yelled at (C1) during medication distribution on 11/3/21. According to the complainant, (C1) was turned away at 8 pm on 11/3/21 when (C1) needed her insulin and was told to leave and come back later. An interview with (C1) revealed she does not like how (S3) treats her. The Department requested dates, times when incidents occurred and stated just multiple times. (C1) claims (S3) does not like how she conducts herself and will yell at her for no reason. An interview with (S3) denies this allegation and states she treats all clients with dignity and respect. (S3) states (C1) is not one to follow the house rules during the distribution of medications and will force herself in front of other clients who have been line waiting. When redirected by (S3), (C1) finds the action to be assertive or rude. Interviews were conducted with clients #3-#10 (C3-C10) revealed (S3) gets along with the others. They all asserted the staff treats 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 allegations mentioned above. (S1-S6) states the staff continues to conduct

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: 3 of 4

Control Number 11-AS-20211105114419

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

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

Allegation: Resident was not assisted with their medication in a timely manner.
It is alleged client #1 (C1) is not assisted with her medication in a timely manner. The complainant reports (C1) was required to take her insulin medication on 11/3/21 and was refused by staff at 8 pm and was told to come back. An interview with (C1) revealed that it was all a misunderstanding and that (C1) did not have any problems with her insulin. (C1) states she has never been denied any of her prescribed meds. (C1) states she is aware of the importance of taking her meds in a timely and is very much aware of the medication distribution schedule. An interview with staff #1-#6 (S1-S6) reports clients are given reminders over their room intercoms and overhead speakers when it is time for medication distribution and it is the client's responsibility. (S1) states if a client is non-responsive to any of the reminders, the staff will ensure to make an in-person visit in their rooms. Interviews with client #2-#10 (C2-C10) all verified they had no issues receiving medications as prescribed and had no concerns with the medication schedule and house rules mandated by the facility. Furthermore, they all agreed that the staff provides numerous notifications throughout the day. 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.

The Department’s investigation consisted of an inspection of the facility, observation, review of (C1’s) service records, 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: "Residents are allowed to smoke in their rooms", "Facility has bed bugs", "Facility is not kept clean", "Staff do not treat residents with dignity", "Staff yells at residents in care" ,and "Resident was not assisted with their medication in a timely manner".

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.

An exit interview was conducted with Ana Kunz and a copy of the report was provided by email.

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