198601766-9-16-2022-11-AS-EMAZ-CK6VJA-20221013162826

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 09/16/2022
Date Signed: 09/16/2022 11:46:30 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
09/08/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220908152239

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: 92	DATE:	09/16/2022
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Ana Kunz		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility illegally evicted resident.

INVESTIGATION FINDINGS:

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On 09/16/22, Licensing Program Analysts (LPAs) Ernand Dabuet and Perry Scott conducted an unannounced subsequent complaint visit and deliver findings. During the visit, LPAs met with administrator Ana Kunz.

The investigation consisted of the following: Interview with facility administrator Ana Kunz and assistant, administrator Mata Fonopo staff #1-#2 (S1-S2), outside agency and witnesses, and reviewed client #1 (C1) service file. A tour of the facility on 09/09/22 and 09/16/22. LPA made several attempts to contact (C1) but was unsuccessful.

Investigation revealed the following: It was reported that client #1 (C1) was sent to the hospital for 51/50 and being held for extended medical observation, but when (C1) is ready to be discharged to return to the facility, (C1) is not welcome back.
Evaluation Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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-20220908152239

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OLIVIA ISABEL MANOR	FACILITY NUMBER: 198601766
	VISIT DATE: 09/16/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

According to the administrator staff #1 (S1), (C1) is non-compliant and refuses to comply with the facility’s house rules. Since 07/07/22 (C1) has refused to continue with his medications, lab work, hygiene maintenance, and obligation to pay rent. (S1) claims she has reached out to (C1’s) case manager and outside agencies for assistance as (C1) requires support that the facility cannot provide. (S1) states she has been unsuccessful with receiving support from any of the agencies. That said, the facility has never refused to accept (C1) back to the facility a as resident. (S1) claims it was (C1’s) case manager (W2) who came voluntarily on 09/02/22 to pick up (C1’s) personal belongings.

According to (S1), there has been no administrative action, written warnings or a written Notice to Vacate have been served to (C1). (S1) affirms that (C1) has not been refused residency at this facility; it was the case manager (W2) who had taken action to voluntarily retrieved (C1’s) personal belongings. An interview with (W2) claims that he thought (C1) was not to return to the facility and perhaps misunderstood the whole situation.

Based on information gathered, an inspection of the facility, observation, analysis of (C1’s) service records, and interviews conducted, the Department found no evidence to support the allegation mentioned in this complaint.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited during this visit.

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC9099 (FAS) - (06/04)

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