198320107-2-12-2025-11-AS-RORN-DE3MPP-20250220084727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320107
Report Date: 02/12/2025
Date Signed: 02/12/2025 02:31:59 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2025 and conducted by Evaluator Alfonso Iniguez

COMPLAINT CONTROL NUMBER: 11-AS-20250207120059

FACILITY NAME:	OAKTREE MANOR		FACILITY NUMBER:	198320107
ADMINISTRATOR:	DADABHOY, MUQEET		FACILITY TYPE:	740
ADDRESS:	3269 SAN ANSELINE AVE		TELEPHONE:	(310) 251-2382
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	6	CENSUS: 6	DATE:	02/12/2025
		UNANNOUNCED	TIME BEGAN:	08:31 AM
MET WITH:	Edilberto Bernardino/Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not meet a resident's incontinence need
Staff did not seek timely medical attention for a resident
Staff did not properly report an incident involving a resident

INVESTIGATION FINDINGS:

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On 2/12/2025 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Edilberto Bernardino / Administrator. LPA Iniguez explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#2) and Resident’s interviews (R#1-R#4). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#3) Identification and Emergency Information, (R#1-R#3) Admissions agreements, (R#1-R#3) Physicians Report or LIC 602A.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

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-20250207120059

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OAKTREE MANOR	FACILITY NUMBER: 198320107
	VISIT DATE: 02/12/2025

NARRATIVE

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Investigation Revealed the Following:

Allegation: Staff did not meet a resident's incontinence need.

The details of the complaint alleged that facility staff is not meeting (R#1)’s incontinence needs.

During the records review, LPA Iniguez observed (R#1)’s Physicians Report for the Residential Care Facilities for the Elderly (RCFE) or LIC 602A dated 9/4/2024, it was marked by a physician that (R#1) did not have a bladder or bowel impairment. In addition, (R#1) can follow instructions and communicate their needs. Moreover, LPA Iniguez reviewed (R#1)’s Admission Agreement dated 11/8/24; it was written that (R#1) did not have additional services, such as incontinence services.

During an Interview with the Administrator (A#1), he stated that the facility has an incontinence schedule, and the facility staff also changes the residents as needed. Moreover, (A#1) stated that (R#1) did not have incontinence while residing at the facility and never used adult diapers.

(R#1) is no longer at the facility, and (W#1) hopes (R#1) is not call regarding this complaint investigation.

During interviews with residents (R#2-R#4), (3) out of (3) stated that the facility staff is tending to their needs, including incontinence services.

During interviews with facility staff (S#1-S#2), (2) out (2) stated that the facility has an incontinence schedule, and, in addition, the facility staff changes the residents as needed. Also, (2) out of (2) facility staff state that (R#1) did not have incontinence while residing at the facility and never used adult diapers.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20250207120059

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OAKTREE MANOR	FACILITY NUMBER: 198320107
	VISIT DATE: 02/12/2025

NARRATIVE

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Allegation: Staff did not seek timely medical attention for a resident.

The details of the complaint alleged that facility staff did not call 911 when (R#1) felt at the facility.

During the records review, LPA Iniguez observed (R#1)’s facility file; LPA did not find incident reports regarding (R#1)’s alleged fall at the facility. In addition, LPA Iniguez reviewed the Regional Office Special Incident Report (SRI) folder, and there are no SRIs regarding the (R#1) incident.

During an Interview with the Administrator, (A#1) stated that (R#1) never fell at the facility while they resided there, so there was no need to call emergency services. Also, (A#1) states that the facility staff tends to the residents' needs as much as possible, including (R#1) while they reside there.

(R#1) is no longer at the facility, and (W#1) hopes (R#1) are not call regarding this complaint investigation.

During interviews with residents (R#2-R#4), (3) out of (3) stated that they feel the facility staff will seek immediate medical attention in case something happens to them.

During interviews with facility staff (S#1-S#2), (2) out (2) stated that (R#1) never sustained a fall while living at the facility; if (R#1) had one, they knew they had to call 911. Also, (2) out of (2) facility staff stated that they make sure all resident's needs are met, including (R#1) 's, while they live here.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250207120059

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OAKTREE MANOR	FACILITY NUMBER: 198320107
	VISIT DATE: 02/12/2025

NARRATIVE

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Allegation: Staff did not properly report an incident involving a resident.

The details of the complaint alleged that facility staff did not report (R#1)’s incident to the appropriated parties (family, doctor, CDSS).

During the records review, LPA Iniguez observed (R#1)’s facility file; LPA did not find incident reports regarding (R#1)’s alleged fall at the facility. In addition, LPA Iniguez reviewed the Regional Office Special Incident Report (SRI) folder, and there are no SRIs regarding the (R#1) incident.

During an Interview with the Administrator, (A#1) stated that they knew that each incident must be reported to the resident’s family, doctor, and CDSS; however, since (R#1) did not fall while they were living at the facility, there was nothing to report.

(R#1) is no longer at the facility, and (W#1) hopes (R#1) are not call regarding this complaint investigation.

During interviews with residents (R#2-R#4), (3) out of (3) stated that they think the facility staff will report to their families and doctors in case something happens to them.

During interviews with facility staff (S#1-S#2), (2) out (2) stated that since (R#1) did not sustain a fall while living here, there was nothing to report. Also, (2) out of (2) facility staff stated that they know that each incident involving a resident must be reported.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20250207120059

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OAKTREE MANOR	FACILITY NUMBER: 198320107
	VISIT DATE: 02/12/2025

NARRATIVE

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During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

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.

An exit interview was conducted, and a copy of the Complaint Report was given to Edilberto Bernardino / Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC9099 (FAS) - (06/04)

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