198601766-4-5-2022-11-AS-MVAO-CF6TBY-20220607143554

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 04/05/2022
Date Signed: 04/05/2022 03:26:11 PM

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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2022 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20220401085625

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: 88	DATE:	04/05/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ana Kunz		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Resident was not accorded dignity in personal relationships with staff and other persons.

INVESTIGATION FINDINGS:

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On 04/05/22 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced visit regarding the allegation(s) above. LPA was met by Facility Administrator, and the purpose of the visit was explained.

Investigation Consisted of : Physical Plant Tour, Staff Interviews, Client Interviews, Requested Documents pertinent to the investigation: Staff and Resident Roster.

Regarding Allegation: “Resident was not accorded dignity in personal relationships with staff and other persons.”
C1 stated that they were not treated with respect, because they were told by staff Monica that what C1 was trying to report, was not their problem. C1 also stated that they were not treated with respect on 03/30/22 by staff member, because they were told to” go to their room. Interviews with staff, clients and record review revealed that there is no Staff named “Monica”, who works at the facility. *** Continued on 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220401085625

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
MONTEREY PARK, CA 91754

FACILITY NAME: OLIVIA ISABEL MANOR	FACILITY NUMBER: 198601766
	VISIT DATE: 04/05/2022

NARRATIVE

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Interviews with Staff generally stated that they have not witnessed any client in care being treated with disrespect, and have not dis-respected any client. Staff 2 Stated that “Clients are asked to clear the hallways, after receiving meds, in case of emergency, due to the narrow hallways. Interviews with Clients in Care, Clients 2-10, generally stated that they have not witnessed other clients in care being dis-respected, and feel that they are being treated with respect by staff.

Therefore; Based on Interviews, Record Review, and Observation the Department finds that :

“Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

An Exit interview was conducted and a copy of this report was provided. No citations were issued during this visit.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC9099 (FAS) - (06/04)

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