198603279-9-24-2021-11-AS-JHAD-C8327T-20211022170916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603279
Report Date: 09/23/2021
Date Signed: 09/24/2021 10:22:14 AM

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
08/12/2021 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210812133820

FACILITY NAME:	MINI MANOR HOME		FACILITY NUMBER:	198603279
ADMINISTRATOR:	RUDES, MIRIAM		FACILITY TYPE:	740
ADDRESS:	1606 S. HOLT AVE		TELEPHONE:	(424) 284-3258
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	6	CENSUS: 4	DATE:	09/23/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Eilat Nahum		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff engaged in a verbal altercation with resident.
Staff not treating resident with dignity.
Resident engaged in an altercation towards resident.
Staff takes residents belongings.

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 Eilat Nahum and explained the purpose of today’s visit.

The investigation consisted of following: Interviews and records review. On 8/19/21 LPA conducted a 10-day health & safety check visit. LPA toured the facility with house manager and requested the following documents: Resident #1 admission agreement, physician report, needs & service, emergency contact and Staff #1-2 training.
The investigation revealed the following:

Staff engaged in a verbal altercation with resident.
On 8/18/21, LPA spoke to Resident (R1). R1 stated words were exchange in the kitchen and Staff (S1) spit in R1’s face. R1 stated was upset threw the food on the floor.
LIC9099-C is on the next page.

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)

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Control Number 11-AS-20210812133820

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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On 9/10/21 LPA interviewed Residents #2-4 and they stated did not see an altercation between resident staff. On 9/20/21, LPA interviewed House Manage (HM) stated there was an altercation between R1 and S1. She stated S1 is always angry and was upset and knocked down the food. She stated did not know what happened. LPA was not able to interview R5 was not present.

Staff not treating resident with dignity.

On 8/18/21, LPA spoke to Resident (R1). R1 stated Staff (S1) is always cursing when communicating. R1stated S1 is always upset and administrator does nothing about it. On 9/10/21 LPA interviewed residents R#2-3 stated staff has not yelled at them. R4 stated staff S1 has yelled at them.

Resident engaged in an altercation towards resident.

On 8/18/21, LPA spoke to Resident (R1). R1 stated a former resident hit him multiple times while on the disable ramp. Resident charge at R1 with a shovel at was hit. R1 stated called 911 due to S1 not calling. R1 stated reported to administrator and she did nothing. On 9/10/21 LPA interviewed Residents #2-4 and they stated have not had altercations with residents and did not see an incident between R1 and the other resident. On 9/20/21, LPA interviewed House Manage (HM) stated there was no altercation between residents.

Staff takes residents belongings

On 8/18/21, LPA spoke to Resident (R1). R1 stated administrator came into the room without permission and took a teapot. On 9/10/21 LPA interviewed Residents #2-4 and they stated staff has not taken their belongings. LPA interviewed House Manage (HM) stated they go into residents’ room once to make sure rooms are clean. She stated they will take residents belongings if they have sharp items.

Based on LPAs 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 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)

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