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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 05/22/2023
Date Signed: 05/22/2023 10:41:03 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
06/13/2022 and conducted by Evaluator Antonine Richard
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220613111818
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:
05/22/2023
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Ana KunzTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff member had a sexual relationship with resident in care.
INVESTIGATION FINDINGS:
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On 05/22/23 Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint Investigation to deliver the findings regarding the allegation listed above. And met with Ana Kunz, the purpose of the visit was explained.
The investigation consisted of the following: On 06/14/2022 LPA Don Senaha initiated the complaint investigation and requested resident roster, staff roster, physicians report, needs and service plans, ID/Emergency contact information, MARs and Admissions Agreements. A plant inspection of the facility was conducted. On 08/16/2022 the Investigator (IB) Olivia Spindola conducted interviews with the administrator, staff S1, resident R1 and witness W1. On 05/22/2023 LPA Richard conducted a tour of the facility and interviewed residents R2 to R5 and staff S2 to S5.
The investigation revealed the following: Record reviews indicate that R1 has documented episodes of hallucinations.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
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 2
Control Number 11-AS-20220613111818
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: 05/22/2023
NARRATIVE
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The Administrator stated that R1 often experiences auditory hallucinations and displays delusional behavior due to their mental illness. Staff interviews revealed that S1 is not comfortable going into R1’s bedroom alone due to R1’s mental illness and tendency to hallucinate. During todays visit R4 out of R85 residents and S4 out of S20 staff disagreed with the allegation.

Regarding the allegation: “Staff member had a sexual relationship with resident in care “Based on observations, interviews and record reviews, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is found to be unsubstantiated.

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

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2