198602864-8-15-2022-11-AS-JHAD-CJQQXR-20220929123352

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602864
Report Date: 08/15/2022
Date Signed: 08/15/2022 04:02:28 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
08/12/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220812094827

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: 5	DATE:	08/15/2022
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Gloria Somintac, House Manager		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility is in disrepair.
Facility is not addressing issues with insects.

INVESTIGATION FINDINGS:

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

The investigation consisted of following: Interviews, Record reviews, and tour of entire facility inside and out. On 08/15/22, LPA Soto interviewed Administrator, S#2, & S#3, R1 - R#3. LPA Soto received the following documents on 08/15/22: Resident roster, Staff roster, Estimate invoice for facility repairs.

Based on the LPA's investigation, the investigation revealed the following. For Allegation – Facility is in disrepair. Interviews with Administrator, S#2, S#3, R#1 - R#3, they all agreed that the facility was in disrepair. The floor broads needed to be repaired. The walls were scratched and had paint peeling. The outside ramp which stretches the back side of the facility is broken. LPA inspected the enitre facility. LPA found that R#1 has the wooded window seal broken. The back yard ramp stretching the back side of the facility is unsafe to walk on or transport anyone on it.

Substantiated

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: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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-20220812094827

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: 08/15/2022

NARRATIVE

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Room #4, West-side & East-side walls are scraped/scratched and have paint peeling. The door frame on the west side has scratches and paint peeled off, Main door bottom half has scratches and paint peeled off. The floor boards near west side wall and south wall have broken and missing slats of wood. The doorway leading to the restroom needs a wooden slat to be replaced. The kitchen cabinets have dirt, grease, and need to be cleaned and painted. The living room ceiling has water mark stains from previous water damage. Interviews and inspections conducted did concur with the allegation above.

Allegation #2 - Facility is not addressing issues with insects. Interviews with S#1, S#2, R#1, & R#2, they all agreed that the facility has had ants. The staff began to treat the entire facility by spraying (Raid.) LPA inspected the entire facility and found dead ants in room #2 and kitchen. In room#4 the staff had placed 4 ant baits to treat the ants. The interviews and inspection conducted did concur with the above allegation.

Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

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

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

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220812094827

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: 08/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/05/2022 Section Cited CCR 873039a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidence by:	1 2 3 4 5 6 7	Administrator to repair, paint, clean and/or replace any material needed to fix problems. Provide pictures of repairs and copy of invoice of repairs completed on or before POC due date.
	8 9 10 11 12 13 14	Based on specific areas of facility needed paint, repair and replacement floor boards. Which poses a potential healtha dn safety risk to the persons in care.	8 9 10 11 12 13 14
Type B 08/19/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidence by:	1 2 3 4 5 6 7	Administrator to treat facility for insects. Provide pictures of treament products used to treat facility on or before POC due date.
	8 9 10 11 12 13 14	Based on ants in the kitchen room #2 & room #4. Which poses a potential healtha dn safety risk to the persons in care.	8 9 10 11 12 13 14

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC9099 (FAS) - (06/04)

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