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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602864
Report Date: 03/10/2023
Date Signed: 03/10/2023 03:51:41 PM

Substantiated


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 CAREFACILITY NUMBER:
198602864
ADMINISTRATOR:STEVEN GRADNEYFACILITY TYPE:
740
ADDRESS:2011 SANTA RENA DRIVETELEPHONE:
(310) 989-1941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 5DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Gloria Somintac, House ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility floor in resident room is in disrepair.
INVESTIGATION FINDINGS:
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This report supersedes report dated 12/01/22. Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions 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.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
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-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: 03/10/2023
NARRATIVE
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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 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 feet 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. Even though, the facility fixed part of the floor issue, it's still in disrepair. The interviews conducted and records reviewed did concur with the above allegation.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An interview was conducted with Gloria Somintac, House Manager and a hard copy of report and Appeal Rights were provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited
CCR
87303(a)
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87303(a) -The facility shall be clean, safe, sanitary and in good repair at all times...This was not met as evidence by: Based on room floor bubbling.
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Administrator to repair and send copy of repair invoice to LPA on or before POC due date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3