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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320013
Report Date: 11/13/2024
Date Signed: 11/13/2024 04:51:09 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
11/12/2024 and conducted by Evaluator Regina Cloyd
COMPLAINT CONTROL NUMBER: 11-AS-20241112123745

FACILITY NAME:SENIOR MANOR CARE IIIFACILITY NUMBER:
198320013
ADMINISTRATOR:STEPHEN GRADNEYFACILITY TYPE:
740
ADDRESS:2423 SANTA FE AVETELEPHONE:
(310) 212-0883
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: DATE:
11/13/2024
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Angelique GradneyTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Staff left resident in soiled diapers for an extended period of time.
Staff did not ensure facility was free of pests.
Staff did not notice residents change in condition.
Staff raised the rent without proper notification.
Staff did not provide resident with the admission agreement.

INVESTIGATION FINDINGS:
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The investigation consisted of the following:

On 11/13/2024, California Department of Social Services (CDSS) Staff conducted a complaint investigation at the above facility to address the following allegations. CDSS Staff met with Staff and explained the purpose of the visit. The Licensee Angelique Gradney and Administrator Virginia Asis joined us later. CDSS Staff conducted resident and staff interviews, toured the facility, and reviewed resident and staff records.

Regarding the allegation "Staff left resident in soiled diapers for an extended period of time,” it is being alleged residents have been left in soiled diapers up to 14 hours on multiple occasions. Four out of four staff interviews indicated they change residents’ diapers on an average of 2-3 times per day or as needed. Interview with the Licensee indicated that Resident #1 (R1) is changed all of the time, and the majority of the facility’s incontinence changes are for R1. Continue to LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
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 5
Control Number 11-AS-20241112123745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SENIOR MANOR CARE III
FACILITY NUMBER: 198320013
VISIT DATE: 11/13/2024
NARRATIVE
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Five out of five resident interviews indicated that their diapers are changed 2-3 times per day or as needed. Resident #2 (R2) indicated that R2’s diaper is changed sometimes seven times a day. CDSS Staff did not observe the smell of incontinence in the facility.

Regarding the allegation “Staff left resident in soiled diapers for an extended period of time," based on interviews and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.


No deficiencies cited for this allegation.

Allegation:

Regarding the allegation "Staff did not ensure facility was free of pests,” it is being alleged the facility has cockroaches and rodents. Three out of three staff interviews indicated they have not seen any vermin or rodents in the facility. The Administrator and the Licensee indicated that the facility has not received any vermin or rodent complaints. Five out of five resident interviews indicated they have not seen any roaches in the facility. CDSS did not observe evidence of vermin nor pests during the facility tour.

Regarding the allegation “Staff did not ensure facility was free of pests," based on interviews and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiencies cited for this allegation.

Allegation:

Regarding the allegation "Staff did not notice residents change in condition,” it is being alleged staff left Resident #1 (R1) unresponsive for an hour and a half. Interview with Staff #3 (S3) indicated S3 observed R1 being unresponsive. Interview with the Licensee indicated S3 informed Witness #2 (W2) of R1’s change of condition. Continue to LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20241112123745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SENIOR MANOR CARE III
FACILITY NUMBER: 198320013
VISIT DATE: 11/13/2024
NARRATIVE
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Regarding the allegation “Staff did not notice residents change in condition," based on interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiencies are being cited.

Allegation:

Regarding the allegation "Staff raised the rent without proper notification,” it is being alleged that Resident #1’s (R1) rent increased from $4000 to $7000. Record review revealed R1’s admission agreement for Senior Manor Care III as of 04/16/2024 includes a monthly rate at $7,500. Interview with the Licensee indicated R1 moved into a small room (#3) at Senior Manor Care III for about three days but R1 wanted a larger private room (#4); thus the monthly rate increase from $4,200 to $7,500 (included incontinence). Licensee indicated that the current rate is based on the size of the room and the new charge did not go into effect until May 2024, but the correct rate is reflected in the admission agreement. Administrator indicated that the admission agreement was signed after R1 moved into the larger room. Monthly statements revealed a $4,200 (April 2024) charge and $7,500 (May - October 2024) charges. Full payments were made until September 2024. Five out of five resident interviews indicated they have not experienced a rate increase.

Regarding the allegation “Staff raised the rent without proper notification," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiencies are being cited.

Continue to LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20241112123745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SENIOR MANOR CARE III
FACILITY NUMBER: 198320013
VISIT DATE: 11/13/2024
NARRATIVE
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Allegation:

Regarding the allegation "Staff did not provide resident with the admission agreement,” it is being alleged that Resident #1 (R1) does not have a signed admission agreement. Record review revealed that Witness #1 (W1) is listed as the responsible person for R1 as of 04/16/2024, W1’s initials are recorded throughout the admission agreement and the agreement is signed by the resident’s responsible party. Interview with the Licensee indicated that W1 signed the admission agreement and received a copy. CDSS Staff observed the initials on admission agreement for Location #2 and Senior Manor Care III agreement are similar. Regarding the allegation “Staff did not provide resident with the admission agreement," based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiency was cited for this allegation.

An exit interview was conducted and a copy of this report was provided to the Licensee Angelique Gradney.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5