198601766-11-19-2025-11-AS-SCIS-DPJ3LX-20251219172128

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 11/19/2025
Date Signed: 11/19/2025 02:07:37 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
10/01/2025 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20251001150347

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: 82	DATE:	11/19/2025
		UNANNOUNCED	TIME BEGAN:	01:47 PM
MET WITH:	Mata Fonopo, Assistant Administrator		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Unlawful eviction
Staff did not provided resident with resources to find a new facility

INVESTIGATION FINDINGS:

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On 11/19/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator Assistant, Mata Fonopo and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:

On 10/2/25 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Resident Appraisal, Admission Agreement, House Rules, 2025 Rent Increase, 7/10/22 Eviction Procedures, 8/28/25 Eviction Procedures, 9/8/25, 30-day Eviction Notice, 8/13/25 and 9/2/25 Behavioral Contracts. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-3 (S1 – S3), and Client -1 (C1).

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025

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 2

Control Number 11-AS-20251001150347

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: 11/19/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Unlawful Eviction

On 10/2/25, LPA Felisa Shirley reviewed C1’s Admission Agreement. C1 has resided at this facility since 2/28/14 per interview with the Administrator Assistant. LPA Shirley observed that C1 signed House Rules most recently, 3/2/23. On 10/2/25, LPA Shirley reviewed 7/10/22 Eviction Procedures, 8/28/25 30-day Notice of Eviction and 9/8/25 30 day Written Eviction Notice dated 9/8/25. Eviction Notice dated 9/8/25 was in compliance and within Title 22 Regulations and was accepted on 9/16/25.

LPA interviewed staff 1 – staff 3(S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed client 1(C1), who confirmed the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation of an “Unlawful Eviction,” therefore, the allegation is unsubstantiated.

Allegation: Staff did not provide resident with resources to find a new facility

It is being reported that staff did not offer resources for client to relocate to another facility. On 10/2/25, LPA Shirley reviewed the 30-day Written Eviction Notice for C1 dated, 9/8/25. LPA observed that the notice included information about resources available to assist C1 to identify alternative housing and care options.

LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed client- 1(C1), who confirmed the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not provide resident with resources to find a new facility,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Administrator Assistant, Mata Fonopo.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025

LIC9099 (FAS) - (06/04)

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