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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603279
Report Date: 11/08/2021
Date Signed: 11/08/2021 04:13:36 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
09/03/2021 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210903123002
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: 3DATE:
11/08/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Eliat NahumTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff not maintaining resident’s hygiene.
Food service not provided to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings for the allegations listed above. LPA met with Nahum and explained the purpose of today’s visit.

The investigation consisted of following: Interviews and records review. On 9/10/21, LPA and LPM conducted a Health & Safety check. LPA conducted interviews with Staff #1-2 and residents #1-3. LPA was unable to interview resident #4 due to not being home and resident #5, no longer lives at the facility. LPA requested the following documents: staff #1-2 training records and residents #1-3 physicians reports and emergency contacts.

Investigation revealed the following:

Staff not maintaining resident’s hygiene.
LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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 2
Control Number 11-AS-20210903123002
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: 11/08/2021
NARRATIVE
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On 9/10/21, LPA interviewed Staff #1 (S1) regarding the above allegation. S1 stated residents are assisted with bathing and if needed changing of clothes. Staff stated resident clothes were washed. LPA attempted to interview staff #2 but staff did not speak English. LPA was not able to interview resident #1, due to no longer living at the facility. LPA interviewed residents # 2-4, all residents stated they have no problem with staff assisting them. On 9/27 and 10/4/21, LPA interviewed the reporting parties, they both stated had seen resident #1 clothes was not clean and nails were dirty. On 10/1/21, LPA asked administrator how often does the staff clean the resident’s clothes? She stated clothes are cleaned every day. She also stated residents that need assistance with showering are bathed in the AM.

Regarding allegation: Food service not provided to resident.

On 9/10/21, LPA spoke interview staff #1 regarding the above allegation. S1 stated residents are provided 3 meals a day and sometimes snack. LPA attempted to interview staff #2 but staff did not speak English. LPA interview residents # 2-6, all residents stated they receive three meals a day and sometimes snacks. On 10/1/21, LPA asked administrator, how often are residents provide food? She stated residents are provided three meals a day. LPA asked was there concern of some residents not eating? She stated there was no concern and if there were caregivers are trained to notify her. LPA interviewed R1’s relative informed resident may not had wanted to eat due to medical condition. On 10/4/21, LPA interview the Reporting Party (RP), RP stated R1 informed staff was not providing food. RP stated had spoken to S1 and informed R1 was refusing to eat and told the administrator. LPA reviewed R1’s records and health conditions may have prevented resident from eating.

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.



Exit interview conducted and report was given to Nahum.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2