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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602381
Report Date: 10/11/2023
Date Signed: 10/11/2023 03:59:02 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
10/06/2023 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20231006165632
FACILITY NAME:MAGNIFICENT MANORFACILITY NUMBER:
198602381
ADMINISTRATOR:MINDA MCNAMARAFACILITY TYPE:
740
ADDRESS:22831 MADRONA AVENUETELEPHONE:
(310) 326-1617
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:6CENSUS: 6DATE:
10/11/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Minda McnamaraTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not ensure that the facility is free from pests.
Staff do not ensure that residents is provided with activities.
Staff do not ensure that residents is provided with an appropriate variety of foods.
Staff are isolating residents.
INVESTIGATION FINDINGS:
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On 10/11/23, Licensing Program Analyst (LPA), Wendy Gibbs, initiated an complaint investigation at the faciltiy listed above. During today's visit LPA met with Administrator, Minda Mcnamara, and explained the purpose of today's visit.

During today's visit LPA toured the facility, interviewed staff (S1-S4) and residents (R1-R6) and received documents pertinent to the investigation. Documents received and rewiewed were Staff Roster, Resident Roster, Menu, Resident Admission Agreement, Physician Report, Pre Apprisail, Needs and Service Plan, and receipts from exterminator company.

Continued on LIC9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
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-20231006165632
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: MAGNIFICENT MANOR
FACILITY NUMBER: 198602381
VISIT DATE: 10/11/2023
NARRATIVE
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Allegation: Staff do not ensure that the facility is free from pests.

The allegation alleges that there are flies and gnats flying around the facility and in the dining area. During todays visit LPA did not observe any insects in the facility. LPA observed two meals served at the facility and did not see any insects in the dining room or kitchen. LPA reviewed documents from the exterminator company that comes monthly. During interviews with staff (S1-S4) four out of four stated they have not seen any insects flying around the facility and the facility is treated monthly for any insects. During interviews with residents (R1-R6) five out of six stated they have not seen any insects in the facility, and one out of six stated they have seen a fly a few times in the facility. 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.

Allegation: Staff do not ensure that residents are provided with activities.

The allegation alleges that residents mostly just sit in their rooms all day, every day because staff do not provide activities. LPA observed residents with a daily newspaper and other materials to read. LPA observed a karaoke book and set up, in the living room available for residents. LPA observed games, activities, and reading material available for residents located in the living room. During interviews with staff (S1-S4) four (4) out of four (4) stated they offer activities, exercise, and outside activities like a walk to residents and encourage them to participate. Three out of three Staff (S2, S3 and S4) stated there are a few residents who choose not to participate in activities. During interviews with Residents (R1-R6) six out of six stated there are activities offered by staff at the facility. Residents (R1, R3, and R5) three out of three stated they do not usually participate in activities because they don’t want to. 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.

Continued on LIC9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20231006165632
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: MAGNIFICENT MANOR
FACILITY NUMBER: 198602381
VISIT DATE: 10/11/2023
NARRATIVE
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Allegation: Staff do not ensure that resident is provided with an appropriate variety of foods.

The allegation alleges that staff give resident the exact same thing to eat every day. During visit, LPA observed breakfast and lunch at the facility, residents had a variety of food to eat. LPA reviewed the sample menu and weekly menu posted and observed a variety of foods provided to residents. During interviews with staff (S1-S4) four out of four stated food is prepared before every meal, and everything they use is fresh. Staff stated they do not serve food left over from previous meals or the same foods every meal. Staff (S2, S3, and S4) stated they have a resident that they make food special for every day because the resident wants what they like. During interviews with residents (R1-R6) five out of six residents stated they get a variety of foods. One out of six residents stated they need soft food otherwise it upsets their stomach, and the staff makes them what they like to eat. 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.


Allegation: Staff are isolating resident.

The allegation alleges that staff do not ensure all residents are taken to communal areas for socialization. LPA observed residents in the dining room visiting and drinking coffee or water. Additionally, LPA observed five residents during lunch eating together. LPA observed R1 in their room and when asked why they were not in the dining room with the others R1 responded because I wanted to stay here. During interviews with staff (S1-S4) four out of four stated residents are encouraged to join other residents during meals and activities. Staff (S2, S3, and S4) three out of three staff stated there are a few residents that tell them “Not today,” when asked if they want to go to the living room, dining room, or outside. During interviews with residents (R1-R6) six out of six stated they are not isolated and have not been isolated. Residents R1 and R3 stated they do not always want to go to the living room or dining room and prefer to stay in their room. 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, Minda Mcnamara, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3