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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602210
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:09:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
08/11/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20230811130350
FACILITY NAME:INDIAN PEAK MANORFACILITY NUMBER:
198602210
ADMINISTRATOR:TORRE, RICARDO DELAFACILITY TYPE:
740
ADDRESS:27102 INDIAN PEAK ROADTELEPHONE:
(424) 206-2292
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90274
CAPACITY:6CENSUS: 5DATE:
10/05/2023
UNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Glenda Marquez-AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff does not ensure that facility is maintained clean and sanitary.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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On 10/4/2023 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez meet with Glenda Marquez/Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted an entire physical tour of the facility and photographs.

Evaluation Report continues LIC 9099-C

Investigation Revealed the Following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
08/11/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20230811130350

FACILITY NAME:INDIAN PEAK MANORFACILITY NUMBER:
198602210
ADMINISTRATOR:TORRE, RICARDO DELAFACILITY TYPE:
740
ADDRESS:27102 INDIAN PEAK ROADTELEPHONE:
(424) 206-2292
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90274
CAPACITY:6CENSUS: 5DATE:
10/05/2023
UNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Glenda Marquez-AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Staff does not ensure that facility is free of odors.
Staff does not ensure that residents' hygiene needs are being met.
INVESTIGATION FINDINGS:
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On 10/4/2023 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez meet with Glenda Marquez/Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: Interview with Administrator(A#1), staff(S#1), residents(R#1-R#4). LPA obtained and reviewed (R#1-R#4) Physicians Report, (R#1-R#4) Medication Administration Record (MAR) September-October 2023, (R#1-R#4) Pre-placement Appraisal Information, client roster, staff roster, resident changing schedule.


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: 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: 2 of 7
Control Number 11-AS-20230811130350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: INDIAN PEAK MANOR
FACILITY NUMBER: 198602210
VISIT DATE: 10/05/2023
NARRATIVE
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Investigation Revealed the Following:
Allegation: Staff does not ensure that facility is free of odors.

During the physical tour, LPA conducted an entire facility tour with the administrator; LPA did not notice or smell foul odors in the common areas or resident rooms. In addition, when LPA arrived at the facility on 10/5/2023 at approximately 9:30 AM, he observed A#1 and S#1 mopping and cleaning the facility floors with cleaning and disinfecting supplies.

During an interview with the administrator(A#1), she stated that she and S#1 mop the floors and clean the surfaces with cleaning and disinfecting products daily (5 times daily) and as needed. In addition, A#1 stated that to prevent odors, she and S#1 clean the facility floors, restrooms, residents’ rooms, kitchen, and other surfaces daily and as needed.

During an interview with staff(S#1), he stated that the facility is clean and does not have foul odors.

During interviews with residents (R#1-R#4), 4 out of 4 stated that the facility is clean, sanitary, and does not have foul odors or smells. In addition, 4 out of 4 residents stated that the facility staff regularly cleans the facility.

Allegation: Staff do not ensure that residents' hygiene needs are being met.

During the records review, LPA observed the following: (R#1-R#4) Physicians Report for Residential Care Facilities for the Elderly/LIC 602. In the case of (R#1 and R#2), both can bathe, dress and groom themselves. For (R#3 and R#4) both residents need assistance with bathing, dressing, and grooming. In addition, LPA reviewed (R#1-R#4) the Admissions Agreement; it is stated that these items are included as basic service: Basic hygiene items such as soap and toilet paper, weekly linen changing, and laundry service.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
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 7
Control Number 11-AS-20230811130350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: INDIAN PEAK MANOR
FACILITY NUMBER: 198602210
VISIT DATE: 10/05/2023
NARRATIVE
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During an interview with the administrator(A#1), she stated that every day, there are two staff members, including her, tending to the needs of the residents, and on the weekends, there are three staff. In addition, (A#1) stated that the hygiene needs of the residents are being met by the facility, which follows a weekly bathing schedule and as needed.

During an interview with staff(S#1), he stated that the facility is meeting the hygiene needs of the residents, and they bathe them every day and as needed in case of incontinence problems.

During interviews with residents (R#1-R#4), 4 out of 4 stated that the facility meets their hygiene needs and takes showers or baths daily or when needed.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is 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, therefore the allegations are unsubstantiated.


California Code of Regulations (Title 22, Division 6, Chapter 8).

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
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: 4 of 7
Control Number 11-AS-20230811130350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: INDIAN PEAK MANOR
FACILITY NUMBER: 198602210
VISIT DATE: 10/05/2023
NARRATIVE
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Allegation: Staff does not ensure that facility is maintained clean and sanitary.

The details of the complaint alleged that the facility is not clean and sanitary.



During the physical tour, LPA and the administrator toured the entire facility; while touring the facility, LPA observed dog feces in one of the bathrooms used by the residents. LPA proceeded to take a photo as evidence of the investigation. The administrator cleaned the feces at that moment. In addition, while touring the back patio, LPA observed cluttered items that could be a potential fall hazard for residents. LPA proceeded to take a photo of these items as evidence of the investigation. Also, LPA observed five small dogs and a dog playpen inside one of the resident rooms; LPA asked the administrator who is the owner of the dogs. The administrator replied: "There are mine." LPA took a picture as evidence.

During the records review, LPA looked at the Facility Program Description in the facility's physical file. The facility does not have pets or therapy pets included in the program. LPA consulted with LPM regarding the dogs, LPM stated that if the facility wants to keep the dogs, they need to submit an addendum to their Admissions Agreement, an addendum to the Plan of Operations, a signature of all residents and their representatives stating that they are okay with the dogs being inside the facility and all dogs must be licensed and with their current shoots.

Allegation: Facility is in disrepair.

The details of the complaint alleged that the facility is in disrepair.

During the physical tour, LPA Iniguez and the Administrator toured the entire facility; LPA found a shattered window panel from the resident's closet in one of the residents' rooms. Also, LPA observed rust in the railing of closet doors in 3 residents' bedrooms. LPA proceeded to take pictures as part of the investigation.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
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: 5 of 7
Control Number 11-AS-20230811130350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: INDIAN PEAK MANOR
FACILITY NUMBER: 198602210
VISIT DATE: 10/05/2023
NARRATIVE
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During this investigation, LPA found sufficient evidence to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D.

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
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: 6 of 7
Control Number 11-AS-20230811130350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: INDIAN PEAK MANOR
FACILITY NUMBER: 198602210
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2023
Section Cited
CCR
87303(a)
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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:
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The licensee will replace the broken door and rusted railing before the POC due date. Proof of correction must be emailed to LPA before the due date.
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Based on observations and photographs, the licensee failed to keep the facility in good repair at all times, having a broken mirror door closet in one of the resident's rooms and rusted closet railings in 3 residents' rooms. This poses a potential health and safety risk to all residents in care.
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Type B
11/02/2023
Section Cited
CCR
87208(a)(1)
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87208 Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
(1) Statement of purposes and program goals. This requirement was not met as evidence by:
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The licensee will submit an addendum to their Admissions Agreement, Plan of Operations, a signature of all residents and their representatives stating that they are okay with the dogs being inside the facility and all dogs must be licensed and with their current shoots as POC. Proof of correction must be email to LPA before POC due date.
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Based on observation and records review, the licensee failed to follow the original facility's Plan of Operations and Admissions Agreement in having four small dogs living inside the facility. This poses a potential health and safety risk to all residents in care.
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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: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7