191671691-4-7-2021-11-AS-MVAO-C36QUL-20210519122856

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 04/07/2021
Date Signed: 04/07/2021 02:45:31 PM

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
09/04/2020 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20200904140454

FACILITY NAME:	CROFTON MANOR INN		FACILITY NUMBER:	191671691
ADMINISTRATOR:	AMALIA ESQUIVIAS		FACILITY TYPE:	740
ADDRESS:	1950 E. 5TH ST.		TELEPHONE:	(562) 437-0093
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY:	213	CENSUS: 111	DATE:	04/07/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Amalia Esquvias		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff is mishandling client's medication while in care
Client sustained a fall while in care
Staff failed to seek timely medical treatment for client while in care

INVESTIGATION FINDINGS:

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04/07/21 Licensing Program Analyst LPA/Jade Jordan initiated a subsequent complaint investigation for the allegation(s) listed above.

Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically with Amalia Esquivias the Facility Administrator.

The investigation consisted of analysis of requested documents, Record Review, and Interviews conducted.

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

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-20200904140454

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: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 04/07/2021

NARRATIVE

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Allegation: Staff is mishandling client's medication while in care

Regarding the allegation that staff is mishandling client’s medication while in care. LPA conducted a record review that revealed the correct dosage of medication was being given to R1, Per Doctor’s orders. The discontinuation of the prescribed medication was not submitted until to the facility and pharmacy until 09/04/20. Lpa interviewed other residents in care, and all generally stated that they get their correct medications.

Based on LPA Record Review, and Interviews the department 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.

Allegation: Client sustained a fall while in care

Regarding the allegation that client sustained fall while in care. LPA’s record review of incident reports documents, that R1 sustained a fall while in care in, the bathroom inside bathtub. R1 was trying to clean their self without assistance. R1 was found by a med tech staff, and LVN was immediately notified. R1 was reminded to call for assistance. Based on LPA Record Review the department 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.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200904140454

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: CROFTON MANOR INN	FACILITY NUMBER: 191671691
	VISIT DATE: 04/07/2021

NARRATIVE

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Allegation: Staff failed to seek timely medical treatment for client while in care.

Regarding the allegation that staff failed to seek timely medical treatment for client while in

Care. Incident report recieved by LPA reflects that R1 was taken to the LVN after fall. LVN examined, and checked that R1 was able to move extremities with no limitations, took vitals, and had caregivers to continue to monitoring for changes. LPA conducted resident interviews, and all generally stated that staff are timely in seeking medical treatment for residents in care.

Therefore; based on LPA Record Review, and Interviews Conducted the Department 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.

No citations were issued during this visit. An Exit interview was conducted, and a copy of this report was given. Advised to sign and return to LPA at Jade.Jordan@dss.ca.gov; or fax at 323-981-1781.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

LIC9099 (FAS) - (06/04)

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