198602864-9-28-2022-11-AS-JHAD-CJQQXQ-20220929123351

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602864
Report Date: 09/26/2022
Date Signed: 09/28/2022 11:55:38 AM

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
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:	09/26/2022
		UNANNOUNCED	TIME BEGAN:	12:33 PM
MET WITH:	Gloria Somintac, House Manager		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not addressing issues with insects.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

This amended report supersedes report dated 08/15/22. 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, 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. Allegation 1 - 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 facility is addressing the issue with the insects. The interviews and inspection conducted did not concur with the above allegation.

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: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

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