198601766-12-26-2025-11-AS-JHAD-DQBR9T-20260114115004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 12/18/2025
Date Signed: 12/26/2025 10:19:18 AM

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
12/16/2025 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20251216141222

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: 86	DATE:	12/18/2025
		UNANNOUNCED	TIME BEGAN:	12:02 PM
MET WITH:	Dario Esguerra		TIME COMPLETED:	03:27 PM

ALLEGATION(S):

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Staff allowed clients to bully another client in care.
Staff mismanaged client's medication.

INVESTIGATION FINDINGS:

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On December 18, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Dario Esguerra, Office Manager greeted the (LPA). (LPA) explained the purpose of the visit is to investigate the allegations mentioned above.

The investigation included a collection of records, and an observation of the facility. The Department obtained several documents, including the Facility Staff Roster (dated 12/17/25), the Resident Roster (dated 12/17/25), service records for Client #1 (C1) Identification and Emergency Information LIC 601 (dated 05/23/24), Physician's Report LIC 602A (dated 01/26/25), Harbor UCLA Medical Records (dated 07/28/25), the Resident Appraisal LIC 603A (dated 02/21/23), the Behavioral Contract (dated 09/02/25), and telecommunication text messages and other pertinent records associated with 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: 12/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025

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 4

Control Number 11-AS-20251216141222

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: 12/18/2025

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff allowed clients to bully another client in care.

It is alleged that the staff failed to prevent Client #1 (C1) from being bullied. Reports indicate that several clients at the facility violated (C1's) personal rights and that no staff members intervened during these incidents, resulting in (C1's) humiliation. No additional details about this allegation have been provided.

On December 17, 2025, between 11:10 AM and 12:15 PM, the Department interviewed clients identified as Client #1 through Client #8 (C1-C8). Seven (7) out of the eight (8) clients were unable to confirm the claim. Clients (C2-C8) stated that they have not experienced or witnessed any harassment or bullying behavior among clients at this facility. The facility staff quickly addresses any prohibited actions against clients. (C2-C6) who are familiar with (C1) and mentioned in the complaint have come forward to express their concerns. They genuinely believe that the claim made against (C1) may not accurately reflect the situation and feel that (C1) could have inadvertently contributed to particular circumstances. Client #1 (C1) was interviewed but opted not to continue with the process, sharing that (C1) is no longer affiliated with Olivia Isabel Manor and would prefer to maintain (C1's) distance from the facility.

On December 17, 2025, and December 18, 2025, between 10:10 AM and 01:59 PM, the Department interviewed staff identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of (5) staff members could not support this claim. (S1-S5) claimed this accusation is false. (S1-S5) stated that (C1) has a history of incidents for failing to abide the facility’s house rules and that (C1) was the one who would instigate these behaviors with other clients. Additionally, (S1-S3) stated that (C1) continues to communicate via text with staff who wish to resolve issues with other staff members and return to the facility.

A review of Client #1 (C1’s) Facility Resident Report (dated 02/11/25 through 07/18/25) and Facility Progress Notes (dated 01/22/25 through 10/08/25) revealed multiple house rule violations by (C1). A review of Harbor UCLA Medical Records (dated 07/28/25), Resident Appraisal LIC 603A (dated 02/21/23), Physician’s Report LICA 602 (dated 01/26/25), and Behavioral Contract (dated 09/02/25) and Telecommunication Text Messages revealed that (C1’s) medical diagnosis contributes to (C1’s) line of thinking/belief system.

(Evaluation Report continues LIC 9099--C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20251216141222

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: 12/18/2025

NARRATIVE

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During the investigation on December 17, 2025, the Department observed staff members interacting with residents and noted that their conduct was appropriate. The Department found that the facility upholds the rights of its clients. Posters detailing Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility.

Based on information gathered, there is insufficient evidence to support the allegation mentioned above.

Allegation #1: Staff mismanaged client's medication.

It is alleged that facility staff mismanaged Client #1's (C1) medication. Reports indicate that (C1) was overmedicated by facility staff. No further details about this allegation have been provided.

During the interview, Client #1 (C1) expressed (C1’s) decision to disengage from the process. (C1) indicated to no longer associated with Olivia Isabel Manor and emphasized a strong desire to maintain distance from the facility.

On December 17, 2025, and December 18, 2025, between 10:10 AM and 01:59 PM, the Department interviewed staff identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of (5) staff members could not validate this claim. (S1-S5) expressed their concern regarding the accusation, describing it as unfounded. They shared that (C1) has faced challenges in consistently adhering to prescribed medications, which could potentially impact (C1)’s mental and physical well-being.

A review of Client #1 (C1’s) Medication Administration Record (dated 08/01/25 through 10/08/25) revealed no discrepancies, completed and maintained in order. A further review of the Harbor UCLA Medical Records (dated 07/28/25), the Resident Appraisal LIC 603A (dated 02/21/23), the Physician's Report LICA 602 (dated 01/26/25), the Behavioral Contract (dated 09/02/25), and telecommunication text messages revealed that (C1's) medical diagnosis profoundly impacts (C1’s) thought processes and belief system, intricately shaping (C1) perspective and understanding.

(Evaluation Report continues LIC 9099--C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20251216141222

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: 12/18/2025

NARRATIVE

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Additional review of staff Medication Training topics included: The “Six Rights” of medication administration, Proper storage and documentation, Recognizing side effects and adverse reactions, and Infection control and universal precautions training completed by staff.

Based on information gathered, there is insufficient evidence to support the allegation mentioned above.

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

An exit interview was conducted with Dario Esguerra and copies were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025

LIC9099 (FAS) - (06/04)

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