198602022-9-26-2024-11-AS-UCOL-DA5VBW-20241017161813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602022
Report Date: 09/26/2024
Date Signed: 09/26/2024 02:51:27 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
09/20/2024 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20240920120324

FACILITY NAME:	HALLDALE MANOR		FACILITY NUMBER:	198602022
ADMINISTRATOR:	BUSTOS, GLENDA		FACILITY TYPE:	740
ADDRESS:	23438 HALLDALE AVENUE		TELEPHONE:	(310) 533-7364
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY:	6	CENSUS: 5	DATE:	09/26/2024
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	ADMINISTRATOR EVANGELINE AGATEP		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff physically abused resident.

INVESTIGATION FINDINGS:

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On 09/26/2024 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Halldale Manor facility and was greeted by Administrator Evangeline Agatep (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the finding pertaining to the above-mentioned allegation.

The investigation consisted of the following: LPA Calderon interviewed Administrator S1, Staff S2-S3, resident R1-R5. LPA Calderon obtained the following records: Needs and Service plan (date 9/1/2024), admission agreement (date 8/13/2024), physician report (date 6/5/2024), pre-placement plan (date 8/10/24), incident report (date 09/16/2024) for R1. Needs and Service plan (date 12/15/2023), admission agreement (date 12/6/2023), physician report (date 10/25/2023) for R2.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240920120324

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: HALLDALE MANOR	FACILITY NUMBER: 198602022
	VISIT DATE: 09/26/2024

NARRATIVE

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Regarding Allegation #1: Staff physically abused resident.

This complaint alleged that staff abused R2. S1 indicates that S1 received notice from staff that R1 signed out of the facility on 09/16/2024 and did not return. S1 indicates that S1 reported R1 missing to the case worker and CDSS. S1 indicates that there is no staff member named “LEO” and S1 indicates that no staff would abuse R2 or any other resident in care. Records indicate: LIC500 lists 7 staff members, and none named Leo. Incident report (dated 09/16/2024) indicates that R1 signed out of the facility and did not return. Reviewed needs and service plan (date 9/1/2024) and physician report (date 6/5/2024) for R1. Records indicate that R1 has health issues. 3 out of 3 staff indicate that no staff member has abused R2 or any other resident in care. R1 no longer lives at facility and could not be interviewed. 3 out 5 residents indicate that no staff has abused any resident. 3 out of 5 residents indicate that they have not seen any staff member hit or abuse another resident. 2 out of 5 residents due to health issues could not answer any questions.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff physically abused resident” is found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the Complaint Report were provided to the Administrator Evangeline Agatep (S1).

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC9099 (FAS) - (06/04)

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