198602381-3-2-2023-11-AS-UCOL-CQTQK6-20230412121347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602381
Report Date: 03/02/2023
Date Signed: 03/02/2023 02:56:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
02/04/2022 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220204131700

FACILITY NAME:	MAGNIFICENT MANOR		FACILITY NUMBER:	198602381
ADMINISTRATOR:	MINDA MCNAMARA		FACILITY TYPE:	740
ADDRESS:	22831 MADRONA AVENUE		TELEPHONE:	(310) 326-1617
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	6	CENSUS: 6	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	01:13 PM
MET WITH:	Pampee Mejia - Assistant Administrator		TIME COMPLETED:	03:29 PM

ALLEGATION(S):

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Resident sustained pressure injury while in care.
Unlawful eviction.
Facility staff did not seek timely medical attention for resident.
POA's request for copies of confidential paperwork declined.
Resident care needs are not being met.
Staff are not safeguarding resident's property.

INVESTIGATION FINDINGS:

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On 3/02/2023 Licensing Program Analyst (LPA) Mario Leon and Licensing Program Manager (LPM) Ulysses Coronel initiated a subsequent complaint visit for the allegations listed above to deliver findings. Today’s complaint investigation was conducted with Pampee Mejia - Assistant Administrator.

The investigation consisted of the following: On 02/10/2022 Licensing Program Analyst (LPA) Don Senaha interviewed residents (R2-R6) and staff (S1-S3). LPA requested service documents for residents s(R1-R6).

Investigation revealed:

Allegation: Resident sustained pressure injury while in care
During interviews S1-S3 verified staff follow the care plans. S1 stated there has been no issues with pressure injuries to residents while in care. On 10/18/2021 S3 reported that R1 developed a wound. Witness (W3) was not able to provide interviews during this investigation.
See LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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-20220204131700

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MAGNIFICENT MANOR	FACILITY NUMBER: 198602381
	VISIT DATE: 03/02/2023

NARRATIVE

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Record reviews and interviews conducted indicate that R1 was under a hospice care plan during the periods of 06/23/2021-10/19/2021 and 10/19/2021-01/10/2022. Hospice records indicates that R1 is at risk of skin breakdown due to existing health issues. Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Unlawful eviction

During interviews R2-R6 stated there are no concerns with an unlawful eviction. S1-S3 stated there are no concerns with an unlawful eviction. Witness W3 was not able to provide interviews during this investigation. Record Reviews indicate that witness W3 discharged R1 from the hospital and did not return R1 to the facility. LPA did not observe any other incident reports regarding an eviction for the facility. Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Facility staff did not seek timely medical attention for resident.

During interviews S1 and S2 verified that W3 called 911 on 01/11/2022. Witness W3 was not able to provide interviews during this investigation. Records indicate R1 was given treatment by S3 on 01/10/2022. Facility records indicate that S1, Administrator and hospice left voice messages for W3 about R1 condition after treatment was complete. Record reviews indicate witness (W3) refused to continue hospice services and called for paramedics on 01/11/2022. Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: POA’s request for copies of confidential paperwork declined.

During interviews S1 stated no resident’s POA request for copies of confidential paperwork was declined. W3 did not verify the POA’s request for copies of confidential paperwork that was declined.
See LIC9099-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220204131700

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MAGNIFICENT MANOR	FACILITY NUMBER: 198602381
	VISIT DATE: 03/02/2023

NARRATIVE

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Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Resident care needs are not being met.

During interviews R2-R6 stated there are no concerns with resident care needs not being met. S1-S3 stated there are no concerns with resident hygiene, S2 stated that residents are bathed at least twice a week. Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Staff are not safeguarding resident’s property.

During interviews R2-R6 stated there are no issues with staff are not safeguarding resident’s property. S1-S3 stated there are no issues with staff are not safeguarding resident’s property. LPA did not observe any other incident reports regarding staff are not safeguarding resident’s property. Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

On 03/02/2023, a copy of the report was printed and left with Pampee Mejia.

End of Report

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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