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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191671691
Report Date: 04/14/2021
Date Signed: 04/14/2021 04:34:03 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2020 and conducted by Evaluator Linda M Almaraz
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200309142552
FACILITY NAME:CROFTON MANOR INNFACILITY NUMBER:
191671691
ADMINISTRATOR:AMALIA ESQUIVIASFACILITY TYPE:
740
ADDRESS:1950 E. 5TH ST.TELEPHONE:
(562) 437-0093
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY:213CENSUS: 113DATE:
04/14/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Assistant Administrator, Francisca VallejoTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Facility has cockroaches
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Linda Almaraz contacted Administrator Amalia Esquivias regarding a complaint investigation for the allegation 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 Francisca Vallejo, Assistant Administrator. LPA Almaraz explained the reason for todays visit.

During the initial investigation Licensing Program Manager (LPM) Christine Yee conducted a telephone interview with the Administrator Esquivias and requested copies of service reports from the facility's pest control vendor for the last six months. Upon receiving documentation, LPM Yee determined that additional investigation was needed to make a finding for the above allegation.

(Continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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 3
Control Number 28-AS-20200309142552
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: CROFTON MANOR INN
FACILITY NUMBER: 191671691
VISIT DATE: 04/14/2021
NARRATIVE
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The investigation consisted of the following: On 3/19/20, LPM Christine Yee interviewed Administrator Amalia and Personnel from the Pest Management Company. On 5/1/20, LPA Almaraz conducted interviews with residents and requested resident roster.

The investigation revealed the following: Allegation: Facility has cockroaches Based on records reviewed and interviews conducted the findings indicate that the facility has a pest control issue and has been receiving treatments by a Pest Company. Reports and interviews indicate only parts of the facility are being treated. Seven (7) out of 9 resident interviews revealed that they have seen either a cockroach, rat or some type of unknown bug in their rooms.

Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Assistant Administrator, Francisca Vallejo and a hard copy was provided via email for signature along with appeal rights.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200309142552
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: CROFTON MANOR INN
FACILITY NUMBER: 191671691
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2021
Section Cited
CCR
87303(a)
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 87303 (a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Facility will ensure they have a contract through Orkin Pest Control for a "Cockroach/Rodent Program" where the exterminator visits the facility monthly for inspections/treatments in order to eradicate the pest problem.
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This requirement is not met as evidence by: During the course of this investigation, LPA discovered that an exterminator treats only 3 rooms in the facility as needed, kitchen, laundry, employee lounge, patios and the outside. Per Administrator, they have pest control issues and based on records reviewed not all rooms are being treated.
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LPA was provided copies of monthly services/treatments at the facility.

***Citation was cleared during today's visit***
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3