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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 04:50:04 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
03/09/2020 and conducted by Evaluator Ulysses Coronel
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200309132542
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: 4DATE:
10/07/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Minda McNamaraTIME COMPLETED:
12:01 PM
ALLEGATION(S):
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Resident developed a prohibited health condition 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 licensee Joseph Sol administrator Minda McNamara. The purpose of this visit is to deliver the findings on the investigation completed by Investigations Branch Supervising Investigator (IB) Donald Arvidson for the allegation listed above.

The investigation consisted of the following: On 03/10/2020 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.

The investigation revealed the following: Regarding the allegation: Resident developed a prohibited health condition while in care. The department received an allegation that resident #1 (R1) developed pressure injuries while in care.
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 6
Control Number 11-AS-20200309132542
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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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 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 having stage III and unstageable pressure injuries then was discharge back 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 hospitalizations on 02/19/2020 and 02/28/2020. Regarding the allegation: Resident developed a prohibited health condition while in care. Based on IBs 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 assessed please see LIC421IM.

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 6
Control Number 11-AS-20200309132542
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 Penalities were assessed please see LIC421IM.
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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 6
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
03/09/2020 and conducted by Evaluator Ulysses Coronel
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200309132542

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: 4DATE:
10/07/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Minda McNamaraTIME COMPLETED:
12:01 PM
ALLEGATION(S):
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Staff over medicated resident.
Resident developed rash while under the care of the licensee.
Staff fabricated resident records.
Staff is rough with resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Complaint Visit to this facility to deliver investigation findings on the above allegations. LPA met with met with administrator Minda McNamara and the purpose of the visit was explained.

The investigation consisted of the following: On 03/10/2021 Licensing Program Manager (LPM) Michael Cava and Supervising Investigator (IB) Don Arvidson conducted resident, staff and witness interviews. On 08/12/2020 LPA conducted review R2’s resident records. On 10/01/2021 LPA interviewed the licensee Joseph Sol, administrator Rosendo Carlo Miranda and staff’s S1 and S2 and requested copies of resident records. On 10/05/2020 LPA conducted R2 and R3’s record reviews.

The investigation revealed the following: Regarding the allegation: Staff over medicated resident. On 03/09/2020 the department received an allegation that staff administered high dosage of medication resulting to resident’s death.
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 6
Control Number 11-AS-20200309132542
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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Record reviews indicate that on 07/13/2016 R2 was diagnosed with Vascular Dementia, on 08/23/2016 was placed on hospice care, on 11/18/2018 R2 was discharged from hospice services due to extended prognosis. On 02/07/2019 R2 was observed with very poor appetite, increased confusion, was diagnosed Senile Brain Degenerative Disease and was placed on Hospice care. On 02/21/2019 R2 was reported as having no pain, on continuous oxygen and non-responsive to stimuli during a routine hospice visit. On 02/22/2019 medical records indicate that R2 died and that Cardiopulmonary Arrest and Senile Degeneration of the Brain as the direct causes of death. On 10/01/2020 S1 stated that “R2 was never in pain, I never needed to help administer pain medication to them.”, S2 stated “I never provided R2 with pain medications.” Regarding the allegation: “Staff over medicated resident” 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.

Regarding the allegation: Resident developed rash while under the care of the licensee. On 03/09/2020 the department received an allegation that staff neglected to change R3’s diapers in turn R3 developed skin rash. 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. R3 stated that they had no complaints against the staff, R3 acknowledged having a small wound on their buttocks and right foot, but said that their doctor and nurse comes to treat them, R3 also stated that their family is aware of the wounds and sees to it that they get proper care. Witness W1 stated that they had no complaints or concerns with the care and supervision provided to R3 and that R3 had wounds when they were at the hospital but believes that the wounds have healed since. Regarding the allegation: Resident developed rash while under the care of the licensee. 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.

Regarding the allegation: Staff fabricated resident records. 03/09/2020 the department received an allegation that the Administrator falsified documents indicating that resident R1 was turned and reposition when R1 was supposed to. On 10/02/2020 the administrator stated that they could not find the turning and repositioning log, they were not able to contact a former staff S3 who oversaw the log. On 10/05/2020 LPA conducted record reviews of R1’s resident records and did not observe records of staff assisting R1 with turning and repositioning. Regarding the allegation: Staff fabricated resident records. 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.

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 6
Control Number 11-AS-20200309132542
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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Regarding the allegation: Staff is rough with resident. 03/09/2020 the department received an allegation that Staff S4 would pull resident R4 on their wrist when transferring causing pain to the resident. 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 4 residents was not available for an interview. R3 stated that they have not seen staff mistreat any residents. Witness W2 stated that they have not seen staff do anything that they felt was wrong around any of the residents. Staffs S1 and S2 stated that they provided R4 with assistance in transferring from their bed to their wheelchair and back by holding them in their hips and waistband while R4 is holding onto their shoulders. On 10/01/2020 the administrator stated that staff S4 was no longer employed at this facility, S4 did not return to work after going on a vacation around March of 2020. Regarding the allegation: Staff is rough with resident. 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 was conducted. A copy of this report rights 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: 6 of 6