198602022-8-20-2025-11-AS-UCOL-DLUVRZ-20250925164046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602022
Report Date: 08/20/2025
Date Signed: 08/20/2025 02:15:15 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
08/12/2025 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20250812145742

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: 6	DATE:	08/20/2025
		UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	GLENDA BUSTOS		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not prevent resident from hitting another resident
Staff did not prevent a resident from pushing another resident

INVESTIGATION FINDINGS:

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On 08/20/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Halldale Manor facility and was greeted by Administrator Glenda Bustos (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 findings pertaining to the above-mentioned allegations.
The investigation consisted of the following: LPA Calderon interviewed Administrator S1, Staff S2-S3, resident R1-R3. LPA Calderon obtained the following records: Needs and Service plan (dated 1/1/2025), Physician Report (dated 8/2/2024), Incident report (dated 08/10/2025) for R1. LPA Calderon toured the facility with S1.
The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

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-20250812145742

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: 08/20/2025

NARRATIVE

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Regarding Allegation #1: Staff do not prevent resident from hitting another resident.

This complaint claimed that staff did not stop staff member from hitting R1 on the head. LPA Calderon and S1 toured the facility. LPA Calderon did not notice any negative interactions between staff and residents. LPA Calderon noted the injury to R1 head appears to be more consistent with R1 contacting the floor vs being struck with a cell phone. Records indicate the following: Physician report and Needs and Service Plan indicate that R1 has cognitive issues and is non-verbal. The incident report indicates that R1 was found on the floor with a bloody forehead. R1 indicates to the police that a female caregiver struck R1 in the head with a cell phone and then pushed R1 while in the wheelchair. The interviews indicate the following: S1 indicates that on 08/10/2025 R1 was found on the floor with a bloody forehead by staff. S1 indicates that 911 was called and R1 was taken to the hospital for treatment. S1 indicates that R1 claimed that a female staff member struck R1 in the head with a cell phone and then pushed R1 while in the wheelchair. S1 indicates that R1 changed R1 story and claimed that a male staff struck him in the head. S2 indicates that R1 was watching TV and lost R1 balance and fell to the ground. S2 indicates that S2 would never strike a resident in care. S1-S3 deny the allegation ever happened. R1 is non-verbal and can only write R1 answers to questions. R1 indicates that an unknown female staff struck R1 in the head causing injury. R1 indicates that R1 wrote down the same version to the police. 2 out 3 residents indicate that no staff has ever abused any resident in care. 2 out of 3 residents indicate that they have not seen any staff member hit or abuse R1.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not prevent resident from hitting another resident” is found to be UNSUBSTANTIATED.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20250812145742

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: 08/20/2025

NARRATIVE

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Regarding Allegation #2: Staff did not prevent a resident from pushing another resident.

This complaint alleged that staff did not prevent a staff member from pushing R1. LPA Calderon and S1 toured the facility. LPA Calderon did not notice any negative interactions between staff and residents. LPA Calderon noted that R1 is bedridden and needs help from staff to move from the bed to R1 wheelchair. LPA Calderon noted that R1 is non-verbal and can only write R1 answers to questions asked. The records indicate the following: The Physician report and Needs and Service Plan indicate that R1 has cognitive issues and is non-verbal and bedridden. The incident report indicates that R1 was found on the floor with a bloody forehead on 08/10/2025. R1 indicates to the police that a female caregiver pushed R1 while in the wheelchair. The interviews indicate the following: S1 indicates that on 08/10/2025 R1 was found on the floor with a bloody forehead by staff. S1 indicates that 911 was called and R1 was taken to the hospital for treatment. S1 indicates that R1 claimed that a female staff member struck R1 in the head with a cell phone and then pushed R1 while in the wheelchair. S1 indicates that R1 claimed the incident happened 3 days prior to 08/10/2025. S1 indicates that R1 changed R1 story and claimed that a male staff struck him in the head and an unknown staff member pushed R1 while R1 was in R1 wheelchair. S2 indicates that R1 was watching TV and lost R1 balance and fell to the ground. S2 indicates that S2 would never strike a resident in care. S2 indicates that no staff member pushed R1 in or out of R1 wheelchair. S1-S3 deny the allegation ever happened. R1 is non-verbal and can only write R1 answers to questions. R1 indicates that an unknown female staff pushed R1 while R1 was sitting in R1 wheelchair. R1 indicates that R1 told the police that R1 did not know who pushed R1. 2 out 3 residents indicate that no staff has ever pushed R1. 2 out of 3 residents indicate that they have not seen any staff member hit or abuse R1. 2 out of 3 residents deny the allegation.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not prevent a resident from pushing another resident” is found to be UNSUBSTANTIATED.

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

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC9099 (FAS) - (06/04)

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