198602864-12-1-2022-11-AS-MVAO-CQ7TBZ-20230323143556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602864
Report Date: 12/01/2022
Date Signed: 12/01/2022 02:57:46 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
11/30/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221130122812

FACILITY NAME:	SENIOR MANOR CARE		FACILITY NUMBER:	198602864
ADMINISTRATOR:	STEVEN GRADNEY		FACILITY TYPE:	740
ADDRESS:	2011 SANTA RENA DRIVE		TELEPHONE:	(310) 989-1941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 6	DATE:	12/01/2022
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Gloria Somintac, House Manager		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility floor in resident room is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted an initial complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Gloria Somintac, House Manager

The investigation consisted of following: Interviews and Record reviews. On 12/01/2022, LPA Soto interviewed S#1 - S#3, R#1 -R#6. LPA toured the entire facility. LPA observed in room #4, that floor boards where bubbling up, seemed as if they had water damage from underneath the floor. LPA requested and received the following documents on 12/01/22: Resident Roster, Staff roster, and Repair Invoice.

Based on the LPA's investigation, the investigation revealed the following.

Allegation: Facility floor in resident room is in disrepair. Interviews with S#1 & S#3, communicated that maintenance had come last week to fix some pipes under the house and were suppose to come back and fix the floor. S#1 informed management about the floor needing repair, but management did not give S#1 a

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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-20221130122812

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: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
	VISIT DATE: 12/01/2022

NARRATIVE

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a time frame when they would be coming back to fix the floor. S#2 communicated that S#2 wasn't sure if he was told about the floor needing repair. Interview with R#1 & R#4, communicated that the floor in room #4 has the floor bubbling up and it's unstable. It's been like that for a few days. They couldn't recall the exact day it occurred. LPA observed the floor in room #4 and it looks like it had water damage and that's why it was bubbling up and it's unstable. When LPA tested the damage floor, it bounced up and down. The floor has about 2 x 2 sq foot of damage. It does look unstable. LPA also reviewed the invoice when the maintenance company came out to fix the plumbing, it was on 11/26/22. The facility was aware and fixing the issue. Management has called maintenance company to come out today to fix the floor. The interviews conducted 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 interview was conducted with Gloria Somintac, House Manager and a hard copy of report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC9099 (FAS) - (06/04)

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