198320326-9-19-2024-11-AS-EMAZ-DA6S4N-20241018133301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320326
Report Date: 09/19/2024
Date Signed: 09/19/2024 03:23:41 PM

Substantiated

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
09/11/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20240911081913

FACILITY NAME:	MANNY'S CARE FACILITY		FACILITY NUMBER:	198320326
ADMINISTRATOR:	NAHUM, MANACHA		FACILITY TYPE:	740
ADDRESS:	1782 S SHERBOURNE DRIVE		TELEPHONE:	(310) 309-0405
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	6	CENSUS: 6	DATE:	09/19/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Eilat Nahum		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff do not ensure facility is in good repair
Staff do not ensure facility is kept in clean sanitary conditions for residents in care

INVESTIGATION FINDINGS:

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On 09/19/24, Licensing Program Analysts (LPA), Wendy Gibbs and Yolando Rosser, conducted an unannounced complaint visit to the facility listed above. LPAs met with Designee Administrator, Eilat Nahum, and House Manager, Noame Leibov, and the purpose of today’s visit was explained.

During today’s visit, LPA conducted a facility inspection, interviewed Resident R1-R4, interviewed Staff S1-S4, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, receipts from ABBA Termite & Pest Control aba Bee Emergency Response Team, and Facility Compliance Checklist.

The investigation revealed the following:

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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 7

Control Number 11-AS-20240911081913

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: 09/19/2024

NARRATIVE

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Allegation: Staff do not ensure facility is in good repair
The complaint allegation alleges that the cold-water knob in the shower and the sink does not work, a light fixture is missing a panel cover, and the ceiling and pieces of the wall are deteriorating and falling.
During the facility inspection, LPAs tested the cold-water knob for the sink and observed it did not turn on. LPAs tested the cold-water knob in the shower and observed it did work properly. LPA observed in the bathroom and in the living room there is a section of the paint on the wall that is peeling. LPAs did not observe a light fixture missing a panel cover.
During interviews with Staff S1-S4, were asked if there is anything in the facility that is in disrepair, three (3) out of four (4) stated to their knowledge there was nothing in disrepair. Staff S4 stated they did not inform S1 or S2 of the sink cold-water knob not working. Additionally, during interviews with S1 and S2 stated when staff or residents inform them of something needing repaired, they call and make arrangements for it to be repaired right away.
During interviews with Residents R1-R4, were asked if the facility is kept in good repair, three (3) out of four (4) stated they are unsure if the facility is in good repair and one resident stated staff do not repair things. Additionally, LPA asked R1 if they let staff know if something needs fixed, and R1 stated no they didn't tell them.

During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 11-AS-20240911081913

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: 09/19/2024

NARRATIVE

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Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

Allegation: Staff do not ensure facility is kept in clean sanitary condition

The complaint allegation alleges that the tile floors in the bathroom and shower are not cleaned.
During the facility inspection, LPA observed the grout between the tiles in the bathroom were observed black, the base board in R1’s room was observed dirty, and the window ledge in the living room and R1's room was observed dirty and had dead insects on it.
During record review, LPA received and reviewed the Facility Compliance Checklist that is conducted weekly which entails S1 and S2 walking the facility to ensure rooms are clean and meet Tittle 22 regulations. LPA reviewed the Facility Compliance Checklist dated 08/5/24, 08/12/24, 08/19/24, and 08/26/24.
During interviews with Staff S1-S4, were asked how often the bathrooms and showers are cleaned, four (4) out of four (4) stated the shower is cleaned after every use and the bathroom is cleaned multiple times a day. Additionally, during interviews with Staff S1-S4, were asked how often the facility is cleaned, four (4) out of four (4) stated the facility is cleaned 3 times a day and as needed.
During interviews with Residents R1-R4, were asked if the facility is kept clean and sanitary, two (2) out of four (4) stated yes, the facility is kept clean. Additionally, during interviews one resident stated the baseboards and windows are not cleaned regularly.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 11-AS-20240911081913

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: 09/19/2024

NARRATIVE

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An exit interview was conducted with Administrator Designee, Eilat Nahum, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 7

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
09/11/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20240911081913

FACILITY NAME:	MANNY'S CARE FACILITY		FACILITY NUMBER:	198320326
ADMINISTRATOR:	NAHUM, MANACHA		FACILITY TYPE:	740
ADDRESS:	1782 S SHERBOURNE DRIVE		TELEPHONE:	(310) 309-0405
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	6	CENSUS: 6	DATE:	09/19/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Eilat Nahum		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff do not ensure facility is kept free of pests

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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 7

Control Number 11-AS-20240911081913

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: 09/19/2024

NARRATIVE

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Allegation: Staff do not ensure facility is kept free of pests
The complaint allegation alleges that the facility has an issue with spiders both inside and outside.
During record review, LPAs received and reviewed invoices from a pest control company ABBA Termite & Pest Control dba Bee Emergency Response Team dated for services received on 1/31/24, 04/03/24, 06/28/24, and 07/26/24. During the facility inspection, LPA observed a spiderweb in the facility entrance, and in R1's room and dead insects on a window ledge in the living room.
During interviews with Staff S1-S4, were asked how they keep the facility free of pests and insects, four (4) out of four (4) stated there is a pest control company that comes out regularly to provide services, they ensure surfaces are clean, and check for insects around the facility.
During interviews with Residents R1-R4, were asked if the facility is kept free of insects, two (2) out of four (4) stated they have seen insects in the facility including a spider and flies.

Unsubstantiated During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with Administrator Designee, Eilat Nahum, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 11-AS-20240911081913

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/03/2024 Section Cited CCR 87303(e)(6)	1 2 3 4 5 6 7	87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped	1 2 3 4 5 6 7	Administrator called and plumber came to replace the knob. LPAs tested the knob and observed it worked properly.
	8 9 10 11 12 13 14	and/or non-ambulatory residents, based on the residents' needs. This requirement was not met as evidence by: Based on observations and interview, LPA observed the cold-water in bathroom 1 did not turn on	8 9 10 11 12 13 14
Type B 10/03/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator will email pictures of the painted walls, cleaned baseboards, and cleaned window ledges to LPA. Administrator will conduct a training with staff regarding cleaning procedure and email training log to LPA at Wendy.Gibbs@dss.ca.gov.
	8 9 10 11 12 13 14	Based on observations and interviews, LPA observed the paint peeling on a section of the wall in the bathroom and living room, window ledge in the living room had dead insects and dirt, and the base board in R1's room was observed dirty.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC9099 (FAS) - (06/04)

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