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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000638
Report Date: 05/05/2020
Date Signed: 05/06/2020 10:55:43 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2020 and conducted by Evaluator Lydia Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200107135818
FACILITY NAME:3K HOME CAREFACILITY NUMBER:
306000638
ADMINISTRATOR:MARIA N.G. MANIMBOFACILITY TYPE:
740
ADDRESS:700 S. PLYMOUTH PLACETELEPHONE:
(714) 774-8653
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 3DATE:
05/05/2020
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Maria ManimboTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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* Staff failed to meet resident’s toileting needs
* Facility restrained resident
* Staff left resident unattended in a hoyer lift
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lydia Martinez contacted the facility to deliver findings via telephone due to COVID-19 and precautionary measures. LPA Martinez identified herself to Administrator Maria Manimbo and discussed the purpose of the call.

During the course of the investigation, LPA conducted interviews with facility Administrator, Witness 1 (W1), Witness 2 (W2) as well as reviewed and obtained copies of Resident 1’s (R1) file which included: Unusual Incident Report dated 12/24/2019, Physician's Report dated 08/19/2019, Identification & Emergency Information, Initial Admission Agreement signed 08/10/2014, Admission Agreement signed 04/18/2016, Medicine Administration Record for 12/2019, unsigned Contract along with Expense statements dated 2/5/2020, emails dated 01/14/2020, 01/18/2020, and pictures of food served to the residents.

(see LIC9099C)

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2020
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2020 and conducted by Evaluator Lydia Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200107135818

FACILITY NAME:3K HOME CAREFACILITY NUMBER:
306000638
ADMINISTRATOR:MARIA N.G. MANIMBOFACILITY TYPE:
740
ADDRESS:700 S. PLYMOUTH PLACETELEPHONE:
(714) 774-8653
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 3DATE:
05/05/2020
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Maria ManimboTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
* Adequate food service is not provided.
INVESTIGATION FINDINGS:
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It was alleged that “adequate food service is not provided.” LPA Martinez interviewed Administrator Manimbo on 01/14/2020, who stated food is always made from scratch and fresh vegetables are served and never frozen. Administrator stated her husband Conrad is a Chef and he is the one who cooks for the facility. On 09/25/2019 and 01/14/2020, LPA interviewed W1 who stated he visits his family member who lives at the facility everyday and is a witness that healthy food is prepared and made from scratch. W1 stated he often stays and eats with his family member because the food is good. On 09/25/2019, LPA Martinez interviewed R1 during a complaint investigation and R1 stated she liked living at the facility and the food is always good because Conrad is a Chef and cooks really good. LPA Martinez conducted a complaint visit on 09/25/2019, an Annual Required on 10/01/2019, and complaint visits on 01/14/2020 and 01/22/2020 and observed food to be sufficient and adequate as required by CCL regulation. Therefore, we have found that the allegation is Unfounded, meaning that it was false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20200107135818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: 3K HOME CARE
FACILITY NUMBER: 306000638
VISIT DATE: 05/05/2020
NARRATIVE
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It was alleged that “staff failed to meet resident’s toileting needs” and staff left resident unattended in a hoyer lift.” During an unannounced visit to the facility in the second week of December, family member and W2 observed R1 on a hoyer lift unattended. In an interview with W2, W2 stated while visiting the facility to assess R1, he observed R1 sitting on the commode. W2 stated he did not observe R1 left unattended on hoyer lift. W2 stated he did observe R1 left unattended sitting on a commode in the bathroom. LPA Martinez interviewed Administrator Manimbo who stated hoyer lift was used for R1 to use the bathroom; if R1 was left alone it was to give R1 privacy while R1 used the bathroom but staff was constantly checking on resident to make sure they were okay.

It was alleged that “facility restrained resident.” Approximately around Thanksgiving, a family member received a photo of R1 that was taken by the Licensee showing how R1 was belted in a wheelchair and could not get out. LPA interviewed Administrator Manimbo who stated she sat R1 on a wheelchair and sat R1 outside to get some sun. Administrator Manimbo stated she did not use the seat belt from the wheelchair on R1 because she is aware it is against CCL regulation. No picture was available upon request from family member and Administrator Manimbo.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the above alleged violations did or did not occur, therefore the above allegations are Unsubstantiated.

An exit interview was conducted with Administrator Manimbo via telephone and a copy of this report was provided to via email. Administrator Manimbo agreed to sign all pages of the report and return the signed copies to LPA August
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2020
LIC9099 (FAS) - (06/04)
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