198602864-1-25-2023-11-AS-UCOL-CPFQYW-20230227113550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602864
Report Date: 01/25/2023
Date Signed: 01/25/2023 04:45:25 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
08/23/2022 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220823160104

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: 4	DATE:	01/25/2023
		UNANNOUNCED	TIME BEGAN:	01:41 PM
MET WITH:	Gloria Somintac, House Manager		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not wearing PPE

INVESTIGATION FINDINGS:

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

On 01/25/2023 Licensing Program Analyst (LPA) Alvizar conducted a visit at this facility to deliver complaint investigation findings. LPA met with House Manager, Gloria Somintac and the purpose of the visit was explained. LPA conducted COVID -19 risk assessment at the front door with Caregiver, Jay Fernandez. Jay said there is no COVID here. Upon entery, LPA observed staff #1 and #2 not wearing a mask.

On 08/26/22 Licensing Program Analyst (LPA) Antonia Alvizar conducted a initial complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Gloria Somintac, House Manager. Upon entery, LPA observed staff #1 and #2 not wearing a mask.

Investigation consisted of following: Interviews, record review, and observations. LPA Alvizar interviewed House Manager, S#2, R#1 - R#4. Received the following documents on 08/26/22: Resident roster and staff schedule. Toured rooms #1 - #4, dining room, living room, and kitchen.

Continue on LIC 9099c

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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-20220823160104

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: 01/25/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

I

Investigation Revealed

Regarding the allegation: “Staff are not wearing PPE”. During interviews conducted on 08/26/2022, it revealed the following: 1 out of 4 residents disagree with the allegation, resident R#1 stated, "No, they do keep up with the mask". 1 out of 4 residents agreed the with allegation, resident R#3 stated, “Yes, they don’t wear their mask” 2 out of 4 residents stated sometimes about the allegation, R#4 stated, “Sometimes, I see staff putting their mask on a lot” 0 out of 2 staff disagree with the allegation, 2 out of 2 staff agreed with the allegation, staff S#1 stated, “Yes, we are not wearing PPE”.

Based on LPA 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 deficiency.

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

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20220823160104

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: 01/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/25/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable, accommodations,...	1 2 3 4 5 6 7	Administrator will instruct and perform training with all staff on when and how to wear mask while working at facility. Administrator will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC due date: 02/07/2023
	8 9 10 11 12 13 14	Based on observations and interviews staff were not wearing a mask. Which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3