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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 10/26/2022
Date Signed: 10/26/2022 03:53:09 PM

Substantiated


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
10/20/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221020102112
FACILITY NAME:OLIVIA ISABEL MANORFACILITY NUMBER:
198601766
ADMINISTRATOR:KUNZ, ANAFACILITY TYPE:
735
ADDRESS:21515 S. FIGUEROA STREETTELEPHONE:
(310) 328-5116
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:110CENSUS: 90DATE:
10/26/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Ana KunzTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not preventing an infestation of bed bugs at the facility.
INVESTIGATION FINDINGS:
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On 10/26/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced visit at this facility and was greeted by Administrator Ana Kunz. LPA spoke to Kunz prior to entering the facility to conduct a risk assessment. Kunz informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA explained the purpose of this visit is to investigate the allegation mentioned above.

The investigation consisted of the following: Interview with facility administrator Ana Kunz (S1) and staff #2-#4 (S2-S4), witnesses #1 (W1), and client #1 (C1). A reveiw of (C1's) service file. A tour of the facility.

Evaluation Report continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
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 5
Control Number 11-AS-20221020102112
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: 10/26/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff are not preventing an infestation of bed bugs at the facility.

It was reported that the facility is not preventing an infestation of bed bugs at the facility. The complainant stated that client #1 (C1) has bugs and was bitten by them.

The Department interviewed client #1 (C1) in room #109 who stated that bed bugs are present in his room and had been bitten by them. (C1) showed the bite marks present on the forearms as evidence. (C1) claimed he had reported the problem to staff #3 (S3) but was unable to provide dates and times when it was reported. The Department inspected the entire room and found live bed bug activity in (C1's) mattress.

The Department inspected the adjacent rooms #112, #108, #111, and #221 and found no live activity of bed bugs. An interview with staff #1-#2 (S1-S2) ensures the facility is being treated on an ongoing basis by Dewey Pest Control. The management provided service agreements and invoices as proof that services are being conducted. (S1-S3) indicated they were unaware of the bed bug activity in (C1's) room. (S1-S3) stated they are not aware of any bed bug activity unless it is reported by the clients or housekeeping. (S1) reports that (C1) is very protective of his room and belongings, and that housekeeping has limited access to the room may have account for unreported activity. On the basis of gathered information and observations, the above allegation is supported by evidence.

The Department has investigated the above allegation, even though the administrator has proofed the facility current service contract and continuous treatments are being performed; the facility remains free from bed bugs. Additional measures must be taken to ensure the facility does not have bed bugs.

Based on the Department's interviews, record reviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (1) are being cited on the attached LIC 9099D.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/20/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221020102112

FACILITY NAME:OLIVIA ISABEL MANORFACILITY NUMBER:
198601766
ADMINISTRATOR:KUNZ, ANAFACILITY TYPE:
735
ADDRESS:21515 S. FIGUEROA STREETTELEPHONE:
(310) 328-5116
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:110CENSUS: 90DATE:
10/26/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Ana KunzTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff did not respond to resident's representative's requests for communication in a timely manner.
INVESTIGATION FINDINGS:
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On 10/26/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced visit at this facility and was greeted by Administrator Ana Kunz. LPA spoke to Kunz prior to entering the facility to conduct a risk assessment. Kunz informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA explained the purpose of this visit is to investigate the allegation mentioned above.

The investigation consisted of the following: Interview with facility administrator Ana Kunz (S1) and staff #2-#4 (S2-S4), witnesses #1 (W1), and client #1 (C1). A reveiw of (C1's) service file. A tour of the facility.

Evaluation Report continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20221020102112
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: 10/26/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff did not respond to resident's representative's requests for communication in a timely manner.
The details of the complaint state that staff #1 (S1) is not responsive in communicating on time. The complaint states that she had made several attempts to get a hold of administrator staff #1 (S1) many times in the past weeks and that telephone calls were never returned. The complainant stated she wanted to address concerns privately to (S1) about (C1's) well-being at this facility. It was uncertain whether the complainant had records of outgoing calls made to the facility for (S1) or the dates and times of these calls. The complainant states when outgoing calls were made, there was no mention of the nature of the call to staff #4 (S4) who answered the main line.

According to (S4) it is within the facility house rules when incoming calls are screened. The callers are asked for the name, the number, and the nature of the call to route the call to the proper staff. (S4) denies receiving calls for the administrator (S1) that were never forwarded or addressed. (S4) claims there is no internal written log of incoming calls. An interview with (S1) claims she has not refused or neglected any calls that have been forwarded to her phone line in the past weeks. (S1) states she is responsive to all internal and external incoming calls and will address them timely.

Interviews with clients #1-#9 (C1-C9) reported no issues with incoming calls from the facility's main phone line. (C1-C9) stated they do not receive incoming calls or it is rare from the facility phone line as they all have their phones.

Based on the 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.

An exit interview was conducted with Ana Kunz, and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20221020102112
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2022
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The licensee shall take measures to keep the facility free of flies and other insects.
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Licensee will ensure the bed bug activity is eradicated. Facility will continue with a service agreement with a pest control contract to resolve bedbug issue. The facility will have to be vigilant and use multiple approaches to solve the problem by taking preventative precautions afterwards by POC 11/9/22.
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This regulation has not been met as evidenced by:
Interview with staff, witnesses and observation has confirmed bed bug activity in Room 109. This violation has potential health and safety risks to resident's in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5