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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603279
Report Date: 09/30/2021
Date Signed: 09/30/2021 07:31:42 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
09/23/2021 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210923094710
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:
09/30/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Eilat NahumTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff did not take visitor's temperature.
INVESTIGATION FINDINGS:
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On 9/30/21, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint investigation for the above listed allegation. LPA met with Eilat Nahum, the facility Administrator and the purpose of the visit was explained.

LPA Brown requested and obtained copies of staff and client roster. LPA conducted an interview with the administrator. LPA reviewed residents #1-4 records. During today’s visit, LPA toured the physical plant. LPA conducted interviews with staff #1 and residents #1-4. LPA was not able to interview was unable to interview staff #2 due to level of communication.

The investigation revealed the following: Interviews, records review and observations.

Regarding allegation: Facility staff did not take visitor's temperature.

LIC 9099-C is on the next page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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 3
Control Number 11-AS-20210923094710
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: 09/30/2021
NARRATIVE
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On 9/30/21, LPA interview Administrator Nahum regarding the above allegation. Nahum stated staff is supposed to check all visitor’s temperature, screen and enter into visitor's log book. Administrator stated staff is trained every couple of months on protocol. LPA conducted an interview with Staff #1, staff stated they check resident’s temperature every day. LPA attempted to interview staff #2 but could not answer any of LPA's questions. Staff #1 was trying to intervene and translate when LPA was speaking to staff #2. LPA interview residents #1-4 and 3 out of 4 residents stated they do not get their temperatures check. Residents #1-3 stated they only get their blood pressures check. LPA interview reporting party and stated was at the facility a couple times and temperature was not taking and wasn’t screen. RP stated Staff #1 doesn’t wear a mask all the time. During today's visit Staff #1 did not screen LPA's temperature or screen. LPA explained to staff #1 and administrator that temperatures of all visitors will need to be taken at the point of entry. Staff #1 later took LPAs temperature and recorded in log bood. LPA reviewed residents #1-4 records and temperatures was not recorded for 9/26/21-9/30/21. LPA did not observe temperature log for staff #1-2.

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: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20210923094710
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: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2021
Section Cited
CCR
87468.1(2)
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87468.1 Personal Rights of Residents in All Facilities
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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 for residents to be provided safe and healthful accommodations. Administrator will provide a statement that she trained staff on temperature checking/screening and documentation by POC due date 10/8/21.
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Based on LPAs interviews and document reviews Staff #1 did not take temperature at entry. Residents #1-4 and staff #1-2 temperatures were not log.

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: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3