198601766-8-4-2020-11-AS-MVAO-BSEQUC-20200812122831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 07/31/2020
Date Signed: 08/04/2020 10:06:31 AM

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
05/19/2020 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200519161827

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: 79	DATE:	07/31/2020
		UNANNOUNCED	TIME BEGAN:	03:29 PM
MET WITH:	Ana Kunz		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is retaining a resident who requires a higher level of care
Facility is not kept clean
Facility staff did not stop resident from smoking in the facility

INVESTIGATION FINDINGS:

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

0n 07/31/20 Licensing Program Analyst, LPA/Ernand Dabuet initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Ana Kunz/Administrator.

The investigation consisted of the following: A tour of the facility was conducted. Telephone/video interview conducted with staff and clients. Copies were obtained from current staff/client roster, (C1)'s a pre-placement appraisal, physician’s report, emergency contact information, needs and service plan, medications, and other pertinent documents about this complaint were reviewed.

Evaluation Report Continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2020

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-20200519161827

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: 07/31/2020

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: “Facility is retaining a resident who requires a higher level of care”

The LPA conducted interviews with witnesses, staff, and clients from this facility, along with client #1 (C1’s) service records were reviewed and found there’s no evidence to corroborate the allegation mentioned above. An interview with the complainant who contacted Adult Protective Services (APS) who then cross reported to Community Care Licensing (CCL) in which a complaint was generated in error. The complainant states this information was intended for (APS) and not a complaint on the board and care facility. The complainant reports the complaint was with (C1’s) placement program. The complainant expressed Olivia Isabel Manor has been great and they are not responsible for (C1’s) decline in health condition. The LPA conducted interviews with staff (S1-S4) all verified (C1’s) health condition has declined since she was admitted in 2018. A verification of (C1’s) medical physician states (C1) needs a higher level of care than what (C1) is receiving from her current board and care. According to (S1) she has been in touch with (C1’s) case manager (W2) from August 2019 through June 2020 regarding her living and health condition. An interview with (W2) verified there have been communicating with the facility to relocate (C1). (W2) claims prior to the pandemic in mid-March 2020, she had contacted six (6) potential facilities and did not get any results to admit (C1) due to all the COVID-19 restrictions. Interviews with (S1-S4) all confirmed that the facility will continue to provide services for (C1) in addition to home health services being performed two (2) times a week until the placement program is able to properly relocate (C1) to a higher-level care home. The facility is active in communications with the placement program and is taking the necessary steps to assist in relocating (C1). Based on the information gathered, there is no evidence to support the allegation mentioned above.

Allegation: “Facility is not kept clean”

It is alleged this facility is unclean. The LPA in the past eight (8) weeks has conducted plant inspection at this facility. The LPA observed the facility to be clean and maintained in order. During the initial visit on 05/28/20 and 07/31/20, LPA observed (C1’s) room appears regular upkeep is maintained routinely for cleanliness. An interview with (C1) confirms that her room is not in disrepair or unclean. LPA has regularly observed housekeeping services being performed in prior inspections. An interview with staff (S1-S4) 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 staff and residents daily.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20200519161827

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: 07/31/2020

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

The clients (C1-C8) reports they are pleased with the upkeep of the facility and state their rooms and floors are clean. The clients (C2-C5) state they have never observed the facility to be unclean or dirty. Based on interviews and observation, there is no evidence to back the allegation.

Allegation: “The facility staff did not stop the resident from smoking in the facility”

It is alleged this facility allows the resident to smoke in her room while in bed. An interview with (C1) states this is false. (C1) states she does not smoke in her room. (C1) she has not been restricted by her physician to quit smoking and continues occasionally smoke outside the patio area. A review for (C1’s) service records reveals there is no physician’s order stating (C1) is prohibited from smoking. An interview with clients (C2-C8) all indicate that smoking is prohibited in rooms and has not observed any clients smoke in their own rooms. An interview with (S1-S4) reports revealed that clients are aware of the mandatory house rules. Smoking indoors is not allowed. This facility has a safe and hazard-free environment. The facility continues to bring up this subject during its monthly staff and resident meetings as a precaution. Based on information gathered, there is no evidence to support the allegation.

Based on information gathered, the LPA did not find sufficient evidence to support allegations, "Facility is retaining a resident who requires a higher level of care", "Facility is not kept clean", "Facility staff did not stop resident from smoking in the facility"

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.

A telephonic exit interview was conducted with Ana Kunz/Administrator and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3