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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603279
Report Date: 11/22/2021
Date Signed: 11/22/2021 03:09:19 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
11/17/2021 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20211117160729
FACILITY NAME:MINI MANOR HOMEFACILITY NUMBER:
198603279
ADMINISTRATOR:RUDES, MIRIAMFACILITY TYPE:
740
ADDRESS:1606 S. HOLT AVETELEPHONE:
(424) 284-3258
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:6CENSUS: 4DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Petrus RawangTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff hits residents while in care.
Staff yells at residents while in care.
INVESTIGATION FINDINGS:
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On 11/22/21 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced visit, to Mini Manor Facility, regarding allegations above. LPA Spoke with Licensee Eliat Naham, and was met by staff Petrus Rawung, the purpose of the visit was explained.

The investigation consisted of the following: Physical Plant tour, Resident Interviews, Staff interviews, Record Review of requested documents (Staff Roster, Resident Roster, Admissions Agreements).

Regarding Allegation: Staff hits residents while in care.
Interviews conducted with Residents in care (R1-R4), revealed that they have not been physically hit by staff, nor have they witnessed any other residents being hit. LPA did not observe any resident to have bruising. All residents generally stated that staff treat them with respect.
Based on Observation, Interviews and Record Review the LPA finds that Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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 2
Control Number 11-AS-20211117160729
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: MINI MANOR HOME
FACILITY NUMBER: 198603279
VISIT DATE: 11/22/2021
NARRATIVE
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Regarding Allegation: Staff yells at residents while in care.

Interviews conducted with Residents in Care (R1-R3) revealed that staff generally treat residents with respect, and do not yell or raise their voice towards residents. R1-R4 generally stated they have not witnessed staff yelling at other residents. Staff interview stated that they do not yell at residents.

LPA did not observe any staff yell at residents while conducting interviews.

Therefore; Based on LPA observation, and interviews conducted the LPA finds that although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An Exit interview was conducted and a copy of this report was provided. No citations issued during this visit.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2