198602022-10-31-2025-11-AS-JHAD-DN43GP-20251103171441

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602022
Report Date: 10/31/2025
Date Signed: 10/31/2025 10:08:43 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
10/29/2025 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20251029091203

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:	10/31/2025
		UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Evangeline Agaptep		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff spoke inappropriately to resident.

INVESTIGATION FINDINGS:

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On October 31, 2025, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Evangeline Agaptep, Admnistrator, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above.

The investigation included interviews, a collection of records, and a tour of the facility. Interviews were conducted with Resident #1 through Resident #5 (R1-R5), Staff #1 through Staff #3 (S1-S3), and Witness #1 (W1). The Department reviewed several documents, including the Register of Facility Residents LIC 9020 (dated 08/01/25), Personnel Report LIC 500 (dated 05/09/25), (R1's) Physician's Report LIC602A (dated 09/24/25), Appraisal/Needs Service Plan LIC 625 (08/02/24) as well as other pertinent records associated with this complaint.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025

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-20251029091203

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: 10/31/2025

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff spoke inappropriately to resident.

The complaint alleges that the staff spoke inappropriately to Resident #1 (R1). It is reported that on October 22, 2025, Staff #1 (S1) told (R1) that (R1) was "so stubborn and challenging," which constitutes a violation of (R1's) resident rights. The report indicated that (S1) was not yelling at (R1) but was close to doing so. No additional information about this situation was provided.

On October 31, 2025, between 10:00 AM and 11:00 AM, the Department interviewed residents identified as Resident #1 through Resident #5 (R1-R5). Five (5) out of the five (5) residents could not support this claim. (R1-R5) commended all facility staff, noting that their interactions were friendly and upbeat. They also mentioned that they had never observed any inappropriate behavior from any staff member, and that staff communicated respectfully with residents. (R1-R5) affirmed that the services provided by the staff were not only responsive but also fully adequate.

Despite this, (R1) refuted the claim, emphasizing that no staff member had referred to (R1) as "stubborn" or "challenging." Additionally, (R1) stated unequivocally that the staff (R1) well and that (R1) felt comfortable and safe living at the facility.

Resident #6 (R6) was not available for an interview.

On October 31, 2025, between 11:01 AM and 12:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) out of the three (3) staff members were unable to recount any incident between a staff member and Resident #1 (R1). All staff confirmed that residents receive professional care and treatment. Staff must complete mandatory training every 30 days, covering personal care, emotional support, behavioral management, safety, health monitoring, communication, documentation, and resident rights. Staff member (S1) denied any harsh verbal treatment of (R1) and claimed that the accusation of calling (R1) "stubborn or challenging" is false.

On October 31, 2025, between 01:10 PM and 01:20 PM, the Department interviewed a witness member identified as Witness #1 (W1). (W1) is unable to validate this claim. (W1) reported not having observed any inappropriate behavior during any visits at this facility.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20251029091203

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: 10/31/2025

NARRATIVE

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(W1) determined that the care services provided to residents are satisfactory and indicate that residents are not being neglected or violated of their rights.

On October 31, 2025, the Department conducted a thorough inspection of the facility. The inspection involved observing staff interactions with residents and examining how caregivers approached their responsibilities. The Department monitored the quality of communication, the appropriateness of activities, and the overall atmosphere within the unit to assess the level of care provided to each resident. The Department observed a staff member professionally interacting with residents.

During the visit, the Department identified that the facility promotes the rights of its residents. Posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. This helps residents know their rights, which supports their well-being.

A review of staff training records confirmed that personnel had completed the mandatory training on Resident Rights in Assisted Living, The Aging Process/Physical Needs of Elderly, Importance & Techniques of Personal Care, Resident Rights/Reporting Elder & Dependent Adult Abuse Communication, and Reporting Incidents and Reporting Requirements, which are essential topics. Further review of the facility's House Rules, which specify "no verbal or physical abuse towards other residents and or staff" and "no use of profanity or abusive language," is mandated by the facility.

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

An exit interview was conducted with Evangeline Agaptep, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025

LIC9099 (FAS) - (06/04)

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