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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 02:06:54 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
08/24/2021 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210824115423
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:
02:30 PM
MET WITH:Romily Tallada, Care GiverTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident is being hit while in care
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 administrator.

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-20210824115423
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 being hit while in care. Interviews with administrator, S#2, & S#3, stated that no one has hit or abused C#1. conservator family member has been making false claims about C#1 because she wants to become C#1 POA. She believes if she makes up false claims about the facility, she will become the new POA, but she doesn’t understand that the court needs to make that decision not C#1 or herself. Interviews with C#2 -C#4, stated that the staff never hits them. LPA Soto cold not interview C#1, C#1 was unavailable. Interviews and records reviewed 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, Administrator, 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