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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603279
Report Date: 09/23/2021
Date Signed: 10/19/2021 12:45:48 PM

Unsubstantiated


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
09/02/2021 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210902113641
FACILITY NAME:MINI MANOR HOMEFACILITY NUMBER:
198603279
ADMINISTRATOR:RUDES, MIRIAMFACILITY TYPE:
740
ADDRESS:1606 S. HOLT AVETELEPHONE:
(424) 284-3258
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:6CENSUS: 4DATE:
09/23/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Eliat Nahum TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident not awarded privacy

INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Martessa Brown and Ulysses Coronel conducted a subsequent complaint visit in order to render investigation findings for the allegations listed above. LPA met with Eliat Nahum, the administrator and explained the purpose of today’s visit.

The investigation consisted of following: Interviews and records review. On 9/10/21, LPA & LPM conducted a 10-day visit and toured physical plant. LPA interviewed Staff #1, residents #1-4. LPA attempted to interview staff #2 but unable to communicate. LPA did not interview resident #5 wasn’t present..LPA requested the following documents: staff #1-2 records and residents #1-3 files. On 9/23/21 LPA conducted R1’s record review.

The investigation revealed the following:

Resident not awarded privacy

On 9/7, LPA interview Reporting Parting (RP) regarding the above allegation. RP stated while R1 was changing in the bathroom and the door was closed, that 2 men open the door.
LIC 9099 on the next pages.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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-20210902113641
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: MINI MANOR HOME
FACILITY NUMBER: 198603279
VISIT DATE: 09/23/2021
NARRATIVE
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RP stated R1 had door on multiple occasions. On 9/10, LPA needed a Spanish Translator LPA Ana Soto for Resident R1. R1 disclosed to LPA Soto, while in the restroom. Staff S1 and S2 kept knocking and pushed the door open while other residents were there and laughing. On 9/10/21, LPA conducted interview with S1, stated R1 had took a long time in the restroom. R1 was not opening the door and had to check on the resident. LPA attempted to interview S2 but could not communicate. On 9/20/21, LPA interviewed House Manger HM, stated no one has barged in on R1. She stated R1 would stay in the restroom for a long-time washing clothes, while others needed to use the restroom. HM stated S1 told her about most recent restroom incident. She stated S1 informed her R1 was taking a long time in the restroom and became nervous and open the door with a key. On 9/10/21, LPA interview residents #2-4, they stated could her a lot of yelling by the restroom but could not actual see what was happening. LPA was not able to interview R5 due to not being there. Resident #2 stated the door was open on R1 and would here yelling. R1's records reviewed that resident had a mental condition that may reflect her responses to the allegation.

Based on LPA's interviews conducted and records review during the investigation.


Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted and report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 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
09/02/2021 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210902113641

FACILITY NAME:MINI MANOR HOMEFACILITY NUMBER:
198603279
ADMINISTRATOR:RUDES, MIRIAMFACILITY TYPE:
740
ADDRESS:1606 S. HOLT AVETELEPHONE:
(424) 284-3258
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:6CENSUS: 4DATE:
09/23/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Eliat Nahum TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility staff speak to resident in an aggressive manner

INVESTIGATION FINDINGS:
1
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3
4
5
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7
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9
10
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12
13
Licensing Program Analysts (LPAs) Martessa Brown and Ulysses Coronel conducted a subsequent complaint visit in order to render investigation findings for the allegations listed above. LPA met with Eliat Nahum the administrator and explained the purpose of today’s visit.

The investigation consisted of following: Interviews and records review. On 9/10/21, LPA & LPM conducted a 10-day visit and toured physical plant. LPA interviewed Staff #1, residents #1-4. LPA attempted to interview staff #2 but unable to communicate. LPA did not interview resident #5 wasn’t present. LPA requested the following documents: staff #1-2 records and residents #1-3 files. On 9/23/21 LPA conducted R1’s record review.

The investigation revealed the following:

Facility staff speak to resident in an aggressive manner
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20210902113641
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: MINI MANOR HOME
FACILITY NUMBER: 198603279
VISIT DATE: 09/23/2021
NARRATIVE
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Facility staff speak to resident in an aggressive manner.

On 9/7/21, LPA interview Reporting Parting (RP) regarding the above allegation. RP stated S1 yells at her. R1 stated on 9/1/21, S1 talked to her in aggressively. On 9/10/21, LPA spoke to R2 and resident stated S1 yells all the time at residents. LPA spoke to R3-R4, stated S1 has not yelled at them but has heard S1 yell at other residents. LPA did not interview R#5 was not present. On 9/10/21, LPA interviewed S1 and staff stated doesn’t yell at resident. LPA attempted to interview S2 but doesn’t speak English. On 9/20/21, LPA spoke to house manager and she stated has not heard staff yell at residents.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

Exit Interview Conducted, appeal rights were explained and a copy of this report was furnished.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 11-AS-20210902113641
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: MINI MANOR HOME
FACILITY NUMBER: 198603279
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2021
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions..

This requirement was not met as evidence by:
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Administrator will have an in service training with all staff on Title 22 regulation section, all residents personal rights are protected. To be free from punishment, humiliation and intimidation. Administrator will provide to LPA by POC due date 9/30/21.
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Based on LPAs interviews, R1 stated S1 yells all the time. Residents stated they have heard S1 yelling a them and other residents.

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: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5