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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606565
Report Date: 05/02/2022
Date Signed: 05/02/2022 12:49:58 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/25/2022 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20220425160205
FACILITY NAME:ELITE MANORFACILITY NUMBER:
197606565
ADMINISTRATOR:GLADYS PERVEZFACILITY TYPE:
740
ADDRESS:1318 PASEO VALLE VISTATELEPHONE:
(626) 967-2614
CITY:SAN DIMASSTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 6DATE:
05/02/2022
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Gladys Pervez, AdministratorTIME COMPLETED:
12:48 PM
ALLEGATION(S):
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Resident is not allowed visitors.
INVESTIGATION FINDINGS:
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On 5/2/22 at 9:43 a.m., Licensing Program Analysts (LPAs) Jewel Baptiste and Valeria Maldonado
conducted an unannounced complaint investigation to the facility. Upon arrival, LPA met administrator
Gladys Pervez, and LPAs explained the reason for this visit is to discuss the above-mentioned allegation.

Prior to this visit, LPA conducted a phone interview with complainant and received a video and written
correspondence between complaint and administrator of refusal of visitation.

During the visit, LPAs toured the facility, conducted R1 file review, and obtained verbal visitation policy, photo of sign posted by front entrance indicating refusal to allow FM to visit R1, resident personal rights, Power of attorney(POA) and admissions agreement. LPAs interviewed residents R1. LPAs Interviewed administrator, Staff S1 and S2.

Report continued on 9099C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
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-20220425160205
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELITE MANOR
FACILITY NUMBER: 197606565
VISIT DATE: 05/02/2022
NARRATIVE
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The investigation reveals the following: Regarding "Resident is not allowed visitors" it is alleged that the
facility is not allowing Resident #1(R1) visitation by Family Member (FM). During the visit LPA conducted
file review and found power of attorney dated 3/10/22 for managing real and personal Property for R1, 2/2 staff confirmed they were told not to allow FM to visit R1. Administrator confirmed denied visit due to FM not complying with R1’s POA visitation calendar. Administrator also confirmed that FM has followed facility visitation policy and they are unsure if there is a restraining order in place. Administrator stated R1 was not informed of FM visit on 4/30/22. Administrator confirmed FM was denied visitation prior to administrator knowledge of POA. Interview with R1 confirmed resident would like to visit with FM.


Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.

Exit Interview Conducted with administrator/ Appeal Rights Provided / A Copy of the Report Issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220425160205
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELITE MANOR
FACILITY NUMBER: 197606565
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2022
Section Cited
CCR
87468.1(a)(11)
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Personal rights of Residents in all Facilities.
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their visitors… permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.

This requirement was not mwet as evidence by:
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Administrator will conduct inservice training with all staff on the topic of Residents Personal Rights. Administrator will submit to Licensing the sign-in sheet with name of topic, staff signatures, the date the training was conducted, and the amount of time for the training.
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 Based on observation, interviews conducted and file review it was revealed by the Administrator, S1 and S2 that the facility have denied FM visitation with R1 due to the request of POA, which poses an potential health, safety, or personal rights risk to persons in care.
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The sign in sheet will be submitted
by the POC due date
HSC
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3