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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 04:12:18 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
09/03/2021 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:
02:00 PM
MET WITH:Eilat NahumTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff unable to communicate residents needs due to language barrier.
INVESTIGATION FINDINGS:
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On 11/8/21 Licensing Program Analysts (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings for the allegations listed above. LPA met with… and explained the purpose of today’s visit.

The investigation consisted of the following: On 9/10/21, Licensing Program Analysts (LPA) Martessa Brown and Licensing Program Manager (LPM) Janae Hammond initiated a complaint investigation regarding the above allegations. LPA conducted interviews with Staff #1-2 and residents #2-4. LPA requested the following documents: Personnel report (LIC 500) and Client Roster, staff # 1-2 training records and residents #1-3 Admissions Agreement, Physicians reports, needs and service.
The investigation revealed the following:

Regarding allegation: Staff unable to communicate residents needs due to language barrier.
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: 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 3
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 S1 regarding the above allegation and had to difficulty during the interview process. LPA had to keep rephrasing question in order for S1 to understand the question. LPA attempted to interview S2, asked staff if a resident had a medical emergency what was the protocol? Staff could not answer and S1 was telling staff what to say. Interviewed residents #2-6 and they stated had difficulties communication with staff #1-2. On 10/1/21 LPA interviewed the administrator, she stated, stated staff members do not have a problem communicating. LPA asked does residents have to rephrase question when they need assistance? She stated they do and S2 doesn’t speak English but S1 would translate. She stated resident #1 spoke only Spanish but they would call someone to translate. On 10/4/21 conducted interview with RP was stated R1 is not mobile and would crawl out of bed and caregivers would help resident back. RP stated there was a language barrier between staff and R1. Based on information obtained there is sufficient evidence to support the above allegation.

Based on LPA observations, interviews which were conducted and 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 being cited on the attached LIC 9099D.

Exit Interview Conducted, appeal rights were explained and a copy of this report was provided 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 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2021
Section Cited
CCR
87411(d)(3)
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87411 (d) (3) Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge … (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability ..
This requirement was not met as evidence by:
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Licensee shall ensure all staffs are able to communicate with residents and visitors to meet resident’s need and able to communicate and understand at all time. Licensee will submit written statement as to how staff #1 and 2 will understand and communicate in order to meet the residents in needs by POC due date 11/15/21.
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Based on observation and interviews conducted, staff cannot communicate with residents. On 9/10/21 LPA had a hard time communicating with staff #1 and Staff #2 could not speak English. This a potential health and safety risk to clients 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: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3