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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602381
Report Date: 10/07/2021
Date Signed: 10/07/2021 04:51:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/12/2020 and conducted by Evaluator Ulysses Coronel
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200312105209
FACILITY NAME:MAGNIFICENT MANORFACILITY NUMBER:
198602381
ADMINISTRATOR:MIRANDA, ROSENDO CARLOFACILITY TYPE:
740
ADDRESS:22831 MADRONA AVENUETELEPHONE:
(310) 326-1617
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:6CENSUS: DATE:
10/07/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Minda McNamaraTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident sustained pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Complaint Visit to this facility and met with administrator Minda McNamara. The purpose of this visit is to deliver the findings of the investigation completed by Investigations Branch Supervising Investigator (IB) Donald Arvidson for the allegation listed above.

The investigation consisted of the following: On 03/10/2021 IB conducted interviews with 2 staff, 4 residents and 2 witnesses. On 05/26/2020 IB interviewed administrator Rosendo Carlo Miranda. IB reviewed facility, staff and resident records, during the course if this investigation.

The investigation revealed the following: Regarding the allegation: Resident sustained pressure injuries while in the care. The department received an allegation that resident #1 (R1) developed pressure injuries from October 2019 to February 2020. Home Health Records indicate that R1 was being treated by a wound care nurse during the months of January and February of 2020, on 12/31/2019 R1 was noted having wound
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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 5
Control Number 11-AS-20200312105209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MAGNIFICENT MANOR
FACILITY NUMBER: 198602381
VISIT DATE: 10/07/2021
NARRATIVE
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 on the left buttocks increasing in size, on 01/12/2020 Physicians order indicate that R1 had unstageable pressure injuries on the left and right buttocks, on 01/20/2020 the wound on R1’s left and right buttock combined as a sacral wound and was unstageable. Home Health Records indicate that R1 had Unstageable and stage III pressure injuries. Hospital records indicate that, on 02/19/2020 R1 was sent to the hospital and was diagnosed with stage III and unstageable pressure injuries then was discharge to the facility and on 02/28/2020 R1 was sent back to the hospital where R1 was admitted. On 05/26/2020 IB interviewed the administrator Rosendo Carlo Miranda who stated that: towards the end of February 2020 R1’s home health nurse advised that “the wound was getting worse and R1 needed a higher level of care”. The administrator also stated that they recommended to R1’s family that “R1 needs to be transferred to a skilled nursing facility”. The administrator stated that “The wound may have been a stage III the last week of R1’s family was arranging the transfer." And after a week and a half the administrator decided to call an ambulance to transfer R1 to the hospital. IB observed that the administrator’s statements seem to coordinate with R1’s hospitalization on 02/19/2020 and 02/28/2020. Regarding the allegation: Resident developed a prohibited health condition while in care. Based on IB’s observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Civil Penalties were assessed on a similar allegation during investigation of another complaint with control number 11-AS-20200309132542.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

An exit interview was conducted, plans of corrections were discussed. A copy of this report and appeals rights were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20200312105209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MAGNIFICENT MANOR
FACILITY NUMBER: 198602381
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2021
Section Cited
CCR
87615(a)(1)
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Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries.
This requirement was not met as evidenced by:
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The licensee will conduct a training about Title 22 Regulation 87615(a)(1) Prohibited Health Conditions. Proof of correctiion will be submitted by POC due date.
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Based on IB’s investigation the licensee failed to ensure that persons with stage 3 and 4 pressure injuries are not retained in a residential care facility for the elderly. R1 who had unstageable and stage 3 pressure injuries was retained at the facility which posed an immediate risk to residents in care.
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Civil Penalties were assessed on a similar allegation during investigation of another complaint with control number 11-AS-20200309132542.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/12/2020 and conducted by Evaluator Ulysses Coronel
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200312105209

FACILITY NAME:MAGNIFICENT MANORFACILITY NUMBER:
198602381
ADMINISTRATOR:MIRANDA, ROSENDO CARLOFACILITY TYPE:
740
ADDRESS:22831 MADRONA AVENUETELEPHONE:
(310) 326-1617
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:6CENSUS: DATE:
10/07/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Minda McNamaraTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff left resident in soiled diapers.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Complaint Visit to this facility, the purpose of this visit is to deliver the findings of the investigation for the allegation listed above. LPA met with administrator Minda McNamara and the purpose of the visit was explained.

The investigation consisted of the following: On 03/10/2021 IB conducted interviews with 2 staff, 4 residents and 2 witnesses. On 05/10/2020 IB interviewed witness #3 (W3). On 05/26/2020 IB interviewed administrator Rosendo Carlo Miranda. IB reviewed facility, staff and resident records, during the course if this investigation. On 09/25/2020 LPA Coronel interviewed witness #4 (W4).

Regarding the allegation: Staff left resident in soiled diaper. The Department received allegations that R1 was always in soiled diapers which may have caused their injuries to break even more. On 03/10/2020 3 out of 4 residents interviewed did not have any concerns regarding the care and supervision being provided to them by the staff, 1 out of 4 residents was not available for an interview.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20200312105209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MAGNIFICENT MANOR
FACILITY NUMBER: 198602381
VISIT DATE: 10/07/2021
NARRATIVE
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On 03/10/2020 staff S1 stated that “R1 had a sore at their bottom and wore diapers and R1 would go pee in their diapers, so their wound area was constantly wet from pee.”, and stated “We changed R1’s diapers when needed and rotated them every 2 hours.” On 09/25/2020 Witness W4 stated that “On 01/21/2020 R1’s bed cover was wet with what smelled, like urine I would go different times after that, to try and see but I did not observe R1 being wet". Regarding the allegation: Staff left resident in soiled diaper. 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, therefore the allegation is unsubstantiated.

No deficiencies cited. An exit interview conducted, a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5