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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607305
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:49:46 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/13/2024 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240813085656
FACILITY NAME:CARRILLO MANORFACILITY NUMBER:
197607305
ADMINISTRATOR:ROWENA MARANTAL-CARRILLOFACILITY TYPE:
740
ADDRESS:14006 SYLVANWOOD AVE.TELEPHONE:
(213) 281-1439
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:6CENSUS: 4DATE:
08/20/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rowena Marantal-CarrilloTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff hit resident
Staff did not treat resident with dignity and respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Rowena Marantal-Carrillo and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Administrator Rowena Marantal-Carrillo, Staff 1-2 (S1-2), and Resident 1 (R1). LPA was unable to interview R2-4 as they were asleep during the visit. LPA conducted phone interviews with R1 FM, R2 FM, R4 FM1-2 and attempted a phone call to R3 FM. LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file and S1-2's staff files and collected copies of documents pertinent to the investigation. LPA additionally conducted a tour of facility inside and out including resident rooms, restrooms, living room, kitchen, dining area and observed reisidents in care.


(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
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-20240813085656
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CARRILLO MANOR
FACILITY NUMBER: 197607305
VISIT DATE: 08/20/2024
NARRATIVE
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Investigation revealed the following: Regarding allegation, Staff hit resident, it is alleged that a facility staff hit a resident with their shin. Name of staff is unknown. Interviews conducted with Administrator Rowena Marantal-Carrillo and S1-2 revealed that staff have not hit R1 or any other resident using their shin or in any kind of abusive manner. Facility staff all stated that all facility residents are treated with dignity and respect at all times. Staff stated that they do not handle any resident in a rough manner. Staff stated that there is a zero-tolerance policy on abuse and will report any type of abuse if they observe any staff physically abusing a resident. LPA conducted interviews with 1 out of 4 residents who stated that staff did not hit them but did handle them in a rough manner when they assist them. 1 out of 4 residents could not state who the staff was. 3 out of 4 residents were not interviewed as they were asleep. LPA conducted phone interviews with R1 FM, R2 FM, R4 FM1-2 who stated that they are satisfied with the services that R1, R2 and R4 are receiving at the facility. They stated that the facility staff are great and tend to the residents' needs at all times. They stated that they do not have any concerns, have never seen any bruising and they have not received any reports from R1, R2 or R4 that they have ever been hit or mistreated by any staff at the facility. R1 FM stated that R1 just moved into the facility and is getting accustomed to living away from home and they do not have any concerns to report. LPA observed 4 out of 4 residents who were all in their rooms during the visit. LPA did not observe any bruising or anything of concern. LPA observed staff tending to residents needs. LPA reviewed staff files and observed that they receive annual training on abuse. Based on statements gathered from interviews conducted with staff, facility residents and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

For allegation, Staff did not treat resident with dignity and respect, it is alleged that facility staff do not treat facility resident(s) with dignity and respect as staff are allegedly "mean" at times. Interviews conducted with Administrator Rowena Marantal-Carrillo and S1-2 revealed that staff have never treated any resident in a mean manner. Facility staff all stated that all facility residents are treated with dignity and respect at all times. Staff also stated there is a zero-tolerance policy on any type of abuse and will report if they observe any staff verbally abusing a resident. LPA conducted interviews with 1 out of 4 residents who stated that they are treated with dignity and respect. 3 out of 4 residents were not interviewed as they were asleep. LPA conducted phone interviews with R1 FM, R2 FM, R4 FM1-2 who stated that they are satisfied with the services that R1, R2 and R4 are receiving at the facility. They stated that the facility staff are great and tend to the residents' needs at all times. They stated that they do not have any concerns, and staff treat the residents with dignity and respect. R1 FM stated that R1 just moved into the facility and is getting accustomed to living away from home and they do not have any concerns to report. LPA observed 4 out of 4
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240813085656
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CARRILLO MANOR
FACILITY NUMBER: 197607305
VISIT DATE: 08/20/2024
NARRATIVE
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residents in the facility and did not observe anything of concern. LPA observed all 4 residents in their rooms. LPA observed staff tending to residents needs and did not observe or hear staff making inappropriate comments to any resident. LPA reviewed staff files and observed that they receive annual training on abuse. Based on statements gathered from interviews conducted with staff, facility residents and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

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

Exit interview held. A copy of the report was provided to Administrator Rowena Marantal-Carrillo.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3