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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602022
Report Date: 09/17/2021
Date Signed: 10/18/2021 02:10:36 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/27/2021 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210827134220
FACILITY NAME:HALLDALE MANORFACILITY NUMBER:
198602022
ADMINISTRATOR:BUSTOS, GLENDAFACILITY TYPE:
740
ADDRESS:23438 HALLDALE AVENUETELEPHONE:
(424) 263-5370
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY:6CENSUS: 5DATE:
09/17/2021
UNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Romily Tallada, Care GiverTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident is missing from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Romily Tallada, the facility care giver.

The investigation consisted of following: Interviews and Record reviews. On 08/31/2021, LPA Soto interviewed Administrator Melanie, S#2 & S#4, C#2 – C#4. CCLD confirmed that C#1 was with Conservator. LPA Soto received the following documents on 08/31/21: Resident Roster, Staff Schedule, MAR’s (August,) Physician’s report, Needs and Services plan, dual power of attorney (health care & financial.)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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-20210827134220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HALLDALE MANOR
FACILITY NUMBER: 198602022
VISIT DATE: 09/17/2021
NARRATIVE
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Based on the LPA's investigation, the investigation revealed the following. For Allegation 1 - Resident is missing from the facility. The interviews with the Conservator stated that her family member took him to the doctor and admitted him to a new facility. They will not be picking up C#1’s belongings. Conservator has 2 POA’s for health decisions and financial decisions for C#1. C#1 was not missing, Conservator did not advise case manager and Administrator that her family member was moving C#1 out of the facility. Interviews with staff and residents, stated that they were not aware where C#1 had gone to. LPA Soto could not interview C#1, C#1 was not available. The interviews and records review conducted did not concur with the above allegation.

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 Romily Tallada, Care Giver, and a hard copy was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2