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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 07/24/2025
Date Signed: 07/24/2025 03:26:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2025 and conducted by Evaluator Troy Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250615205708
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: 83DATE:
07/24/2025
UNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:FAAMAMATA FONOPO - ASSISTANT ADMINISTRATORTIME COMPLETED:
03:09 PM
ALLEGATION(S):
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Illegal eviction.
INVESTIGATION FINDINGS:
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On 07/24/2025 Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit to deliver findings. LPA met with Assistant Administrator Faamamata Fonopo and the purpose of the visit was explained. LPA was granted entry into the facility.


CONTINUED ON LIC9099 - C




Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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-20250615205708
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OLIVIA ISABEL MANOR
FACILITY NUMBER: 198601766
VISIT DATE: 07/24/2025
NARRATIVE
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The investigation consisted of the following

On 06/20/2025 LPA Watson reviewed and obtained Client Roster (06/13/25), Employee Roster (06/13/25), Special Incident report (06/13/25), Final Report Psychiatry ED Progress Notes (06/13/25) (06/13/25), Medical Evaluation/Physicians Orders (05/03/25), Harbor -UCLA Medical Center / Discharge Instructions (06/12/25), Physicians Orders (06/01/25 – 06/30/25), Initial Evaluation (01/04/25), Physicians Orders (06/01/25-06/30/25) Special Incident Report SIR (05/28/25), Discharge Instructions (05/30/25). LPA Watson conducted interviews with Clients #1 - #3 and Staff#1 – Staff#3.
The investigation revealed the following:


CONTINUED ON LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250615205708
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OLIVIA ISABEL MANOR
FACILITY NUMBER: 198601766
VISIT DATE: 07/24/2025
NARRATIVE
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Allegation: Illegal Eviction.

It is alleged that Client #1, (C1) was illegally evicted from the facility and not allowed to return. On 06/20/2025 between 12:51 PM and 1:45 PM LPA interviewed Staff #1-Staff #3 (S1-S3). 3 out of 3 staff denied that an illegal eviction notice was served to C1. On 06/20/2025 between 1:45 PM – 4:59 PM, LPA interviewed Clients #1 – Clients #3 (C1-C3): 2 out 3 clients interviewed denied that they were served or received an eviction notice. 1 out of 3 clients interviewed stated that they were served an illegal eviction notice but it was immediately taken away. On 06/20/2025 LPA Watson conducted an interview with the Administrator Ana Kruz, and she stated that she never served C1 with an eviction notice. LPA Watson requested and did not receive an eviction notice because it was never given. Based on record reviews, staff and client interviews and observations there is insufficient evidence to support the allegation: Illegal Eviction. 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 the Assistant Administrator Faamamata Fonopo and a copy of this report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3