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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320326
Report Date: 10/05/2023
Date Signed: 01/25/2024 12:40:10 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
10/02/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20231002144324
FACILITY NAME:MANNY'S CARE FACILITYFACILITY NUMBER:
198320326
ADMINISTRATOR:NAHUM, MANACHAFACILITY TYPE:
740
ADDRESS:1782 S SHERBOURNE DRIVETELEPHONE:
(310) 309-0405
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:6CENSUS: 3DATE:
10/05/2023
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:ASSISTANT ADMINISTRATOR EILAT NAHUMTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
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9
Staff did not provide a safe and comfortable environment
Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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13
THIS REPORT SUPERSEDES THE REPORT DATED 10/05/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: UNSUBSTANTIATED

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility on 10/05/2023 and was greeted by Administrator Manacha Nahum (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10-day visit on 10/05/2023. LPA Calderon initiated an investigation for the above-mentioned allegations and conducted in-person interview with Assistant Administrator Eilat Nahum (A1).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
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 11-AS-20231002144324
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: MANNY'S CARE FACILITY
FACILITY NUMBER: 198320326
VISIT DATE: 10/05/2023
NARRATIVE
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Investigation consisted of: LPA Calderon interviewed A1, S1-S2, and R1-R3. These interviews were conducted on 10/05/2023. LPA Calderon obtain and reviewed the following: physician’s report (dated 08/22/2023), Preplacement Appraisal (dated 07/27/2023) Medical Administration Record (10/2023), Incident report (dated 10/02/2023) for R1.

The investigation revealed the following:

Regarding Allegation #1: Staff did not provide a safe and comfortable environment.

This complaint alleged that staff left a pair of scissors in R1 room unattended. On 10/05/2023 LPA Calderon obtained and reviewed the following: Service Records reviewed for (R1) revealed Preplacement Appraisal (dated: 07/27/23 and Physician’s Report (date: 08/22/2023), (R1) is not independent and requires assistance with activities of daily living (ADL). LPA Calderon conducted an interview with Assistant Administrator Eilat Nahum A1. A1 states that staff did not leave a pair of scissors unattended anywhere in the facility. A1 states that all knives and scissors are locked up in the kitchen. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that all knives and scissors are locked up and no scissors were left unattended anywhere in the facility. LPA Calderon conducted an interview with R1. R1 states that on an unknown date and unknown time R1 states that that unknown staff left a pair of scissors near R1 bed and R1 did not feel safe. LPA Calderon conducted an interview with R2-R3. 2 out of 3 residents state that they feel safe living at the facility and 2 out of 3 residents state that they have not seen a pair of scissors left unattended by staff.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20231002144324
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: MANNY'S CARE FACILITY
FACILITY NUMBER: 198320326
VISIT DATE: 10/05/2023
NARRATIVE
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3
4
5
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8
9
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Regarding Allegation #2: Staff mismanaged R1 medication.

This complaint alleged that staff left an open bottle of pills in R1 room unattended. On 10/05/2023 LPA Calderon obtained and reviewed the following: Service Records reviewed for (R1) revealed Preplacement Appraisal (dated: 07/27/23 and Physician’s Report (date: 08/22/2023), (R1) requires assistance with administration of medications. LPA Calderon conducted an interview with Assistant Administrator Eilat Nahum A1. A1 states that staff did not leave an open bottle of pills unattended anywhere in the facility. A1 states that all medications are locked up in the kitchen. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that all medications are locked up and no open bottles of medication were left unattended anywhere in the facility. LPA Calderon conducted an interview with R1. R1 states that on an unknown date and unknown time R1 states that that unknown staff left an open bottle of pills near R1 bed and R1 states that this happened many times but R1 does not remember when this incident happened. LPA Calderon conducted an interview with R2-R3. 2 out of 3 residents state that staff take care of their medications with no issues and 2 out of 3 residents state that they have not seen an open bottle of pills left unattended by staff.



Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “staff did not provide a safe and comfortable environment” “staff mismanaged residents medication” is found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Assistant Administrator Eilat Nahm A1.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3