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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 05/12/2023
Date Signed: 05/12/2023 07:33:47 PM

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
05/08/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230508084752
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: 85DATE:
05/12/2023
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Dario Esguerra & Mata Fonopo TIME COMPLETED:
04:59 PM
ALLEGATION(S):
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Unlawful eviction.
Staff did not prevent a resident from making inapprorpriate comments towards another resident.
Staff did not prevent physical altercation between residents.
INVESTIGATION FINDINGS:
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On 05/12/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced visit at this facility and was greeted by House Manager Dario Esguerra. LPA spoke to Kunz on the phone prior to entering the facility to conduct a risk assessment. Kunz informed LPA that the facility has COVID cases. LPA explained the purpose of this visit is to investigate the allegations mentioned above.

The investigation consisted of the following: Interview with facility administrator Ana Kunz (S1) and staff #2-#6 (S2-S6), clients #1-#8 (C1-C8). A reveiw of admissions agreement, house rules, physcian's report, resident's appraisals, incident report, police report and other documents associated with this complaint. A tour of the facility was conducted.

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: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
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 3
Control Number 11-AS-20230508084752
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: 05/12/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Unlawful eviction.

The details of this complaint stated the facility owner wrongly evicted client #1 (C1). The complainant stated (C1) was not given a 30-day Notice nor given a reason not to return to the facility. The complainant did not have further information regarding this allegation. An interview with (C1) stated he had a physical altercation with client #2 (C2) on 03/23/23 and was arrested by Carson Sheriff Station. Upon (C1’s) return to the facility (C1) was informed by a staff that (C1) could no longer live at the facility. (C1) did not have the name of the staff who made this statement. (C1) reported being homeless for several days until the hospital found (C1) a place to live. Interviews with staff #1-#6 (S1-S6) dispute this claim. (S1-S2) stated once (C1) was apprehended for elder abuse on 03/23/23, no staff had heard from (C1). There were no calls to the facility for (C1’s) return. (S1-S2) stated (C1’s) room was available and all of (C1’s) personal items remained in (C1's) room. (S1-S2) stated the facility did not issue a 30-day written notice to (C1). (S6) reported that (C1) returned to the facility unannounced on 04/03/23 after being absent for (11) days. (S6) stated no one informed (C1) that (C1) could not return, however, due to (C1’s) arrest of elder abuse, (C1) needed to speak with management. (S2) stated that (C1) had voluntarily terminated the residency. It was (C1’s) decision not to return to the facility when (C1) picked up all personal belongings on 04/03/23. (S2) reported that (C1) already had a place to live at Faith Manor in Los Angeles. The Department verified the information with witness #1 (W1) who reported that (C1) was admitted at Faith Manor on 03/31/23 and left voluntarily on 04/21/23. (C1) was referred by the hospital, and (C1) was never homeless nor was evicted from Olivia Isabel Manor. According to (W1), (C1) was in a local hospital after (C1's) arrest and discharged on 03/31/23 from the hospital, (C1) had a space at Faith Manor immediately after hospital discharge. Based on the information provided, there is no evidence found to support the allegation mentioned above.



Allegation: Staff did not prevent a resident from making inappropriate comments towards another resident.
Staff did not prevent physical altercation between residents.

It is alleged that staff failed to prevent resident #2 (C2) from making unsuitable comments and failed to prevent a physical altercation between (C1) and (C2). The complainant reported that (C2) called (C1) the “N” word. The complainant claimed there were no witnesses to observe this incident. An interview with (C1) reported (C2) called (C1) the “N” word while in the dining hall on 03/23/23. (Evaluation Report continues on LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230508084752
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: 05/12/2023
NARRATIVE
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(C1) admitted punching (C2) in the face only after (C1) had been struck by (C2) in self-defense. (C1) admitted to the physical assault on an elderly and was apprehended by Carson Sheriff on 03/23/23. (C1) admitted the statements made on the police report were accurate. An interview with (C2) contradicts (C1) description of the incident. (C2) stated that (C1) started the harassment in the dining hall and was told by staff #7 (S7) to leave (C2) alone. (C2) claimed (C1) walked out of the dining hall during lunch after being told by (S7). (C2) claimed that (C1) pursued (C2) later in the day and approached (C2) and started beating on (C2). (C2) was unconscious when (C2) felt back. (C2) denied calling (C1) the “N” word. The racial attacks and tension between both clients were denied by staff #1-#6 (1-6). In a written statement staff #7 (S7) claimed she observed the incident on 03/23/23 when (C1) was the instigator and was told to stop bothering (C2). (S7) claimed she intervened before the situation escalated. Clients #3-#8 (C3-C8) knew about the incident between (C1) and (C2) through hearsay and were not actual witnesses. (C3-C8) indicated that staff is responsive in preventing violence among residents. The Department obtained a police report that indicated (C1) was the perpetrator, not the victim. (C1) was apprehended for elder abuse in violation of 368(b) (1) penal code. (C1) revealed making an original statement giving (C2) a “Two-piece” a (common street term for punching someone twice) for simply looking at (C1). (C2) who is considered elderly at (65 y/o) sustained face injuries and was rushed to the hospital. (C1) admitted lack of empathy or remorse for the actions. Based on the information provided, there is no evidence found to corroborate the allegations mentioned above.

Based on the information gathered, an inspection of the facility, observation, analysis of records, and interviews conducted, the Department found no evidence to support the allegations mentioned in this complaint.

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

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

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3