<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603461
Report Date: 01/13/2023
Date Signed: 01/13/2023 04:43:41 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2023 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230104092941
FACILITY NAME:NEWCOMB GUEST MANORFACILITY NUMBER:
198603461
ADMINISTRATOR:GUEVARA, SUSANAFACILITY TYPE:
740
ADDRESS:10647 NEWCOMB AVETELEPHONE:
(562) 902-1943
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:6CENSUS: 5DATE:
01/13/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Iwona Kaya, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff was having sex with their boyfriend at the facility.
Uncleared adult at the facility.
Facility did not provide a comfortable environment for resident.
Facility did not provide a safe environment for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA) Galarza & Erik Zaragoza conducted an initial 10-Day complaint visit to investigate the above allegations.The purpose of the visit was discussed caregiver staff Marietta Woller. Administrator Iwona Kaya arrived shortly after.

The investigation consisted of: An inspection of the interior and exterior physical plant was conducted. Staff (S1-S4) and residents (R1- R5) were interviewed. Resident (R6) was not present and was interviewed telephonically. Resident file documents: [Identification and Emergency Information, Preplacement Appraisal, and Physician's Reports were reviewed and obtained. Former staff (S5's) Personnel Record, LIC 500 Personnel Report, and resident roster were obtained.

See LIC 9099C for report continuation.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
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 28-AS-20230104092941
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NEWCOMB GUEST MANOR
FACILITY NUMBER: 198603461
VISIT DATE: 01/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Facility staff was having sex with their boyfriend at the facility. It is alleged that a caregiver staff's boyfriend slept over the facility between dates November 24, 2022 - December 2022. On multiple times, former caregiver staff (S5) and boyfriend were overheard having sex, as well engaging in arguments. Two (2) out of six (6) residents confirmed that they overheard staff (S5) and boyfriend have sex with it's boyfriend. Four (4) out of six (6) residents stated that they overheard staff (S5) argue with boyfriend during nighttime hours. All staff interviewed denied having knowledge that former staff (S5) had sex with boyfriend in the premises. Staff (S5) worked temporarily at the facility between November 1, 2022 - December in order to provide staff coverage because another staff was on an extended vacation. There are 2 caregiver rooms in the home. Former staff (S5) was living in the caregiver room next to the office that has an entrance on the north side yard. Staff stated it is possible that staff (S5) sneaked in it's boyfriend since the caregiver door leads to the side yard. Administrator stated that S5's boyfriend was not allowed to sleep/reside in the property. However, staff stated that sometimes staff (S5's) boyfriend parked in the garage driveway and slept in it's vehicle.

Allegation: Uncleared adult at the facility. It is alleged that former staff (S5's) boyfriend slept at the facility over night while staff (S5) worked at the facility. Based on interviews conducted, the findings indicate that Administrator hired S5's boyfriend to paint the interior of the house as a third party contractor. The project lasted approximately two (2) weeks. The boyfriend worked at the facility from 10:00 am - 9:00 pm. Administrator stated that livescan fingerprints were not obtained. However, since the "boyfriend" spent at minimum 11 hours a day three (3) to four (4) times a week at the facility and was observed by residents staying and hanging out in caregiver's room there is sufficient evidence to corroborate that former staff (S5's) boyfriend required criminal record clearance. Four (4) out six (6) residents stated they observed staff (S5's) boyfriend inside the facility during daytime and nighttime hours. In addition, staff (S4) began working at the facility in late December and has not been associated to the facility. Administrator Iwona Kaya stated she does not have access to Guardian database because former Administrator is still the account user.

See LIC 9099C for report continuation

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230104092941
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NEWCOMB GUEST MANOR
FACILITY NUMBER: 198603461
VISIT DATE: 01/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Facility did not provide a comfortable environment for resident. It is alleged that the facility has narrow doorways that make it difficult to ambulate to and from when using a wheelchair and/or walker. Based on physical plant inspection observation three (3) out of four (4) resident bedrooms had doorways that were narrow in size, of which a regular size wheelchair and walker could not fit in order to exit the door. One (1) resident bedroom is missing a door due to the narrow doorway entrance. The resident that lives in the room requires wheelchair and walker devices. These assist devices could not safely exit the room door if there was a door. Three (3) out of six (6) residents stated the facility does not provide a comfortable environment. All staff stated the facility is comfortable. However, staff acknowledged the bedroom doorways are narrow and some resident's wheelchairs and walkers are not able to fit through the doorway.

Allegation: Facility did not provide a safe environment for resident. It is alleged that the facility has tripping hazards, such as uneven floors inside the facility due to different flooring types i.e. tile, laminate flooring, and flooring trim transitions. Based on observation, different types of flooring trim transitions were observed throughout the facility. In addition, the backyard concrete pavers were raised at least 3 inches posing a tripping hazard for residents and staff. The backyard had a wood plank planter divider that was raised approximately 6 inches from the floor. The wood plank had nails sticking out of the wood. Discarded furniture debris was also observed in the north side of the yard. The facility has two side yard passageways; only the north side has an exit to the front of the property. The north side exit door had a lock that required a key on the door. Administrator immediately unlocked the lock and removed the lock. Therefore, observations made corroborate the allegation.

Based on interviews conducted, record review, and observations, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. Deficiencies are cited. See LIC 9099D.

Exit interview was conducted with Administrator Iwona Kaya. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230104092941
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NEWCOMB GUEST MANOR
FACILITY NUMBER: 198603461
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2023
Section Cited
CCR
87411(d)
1
2
3
4
5
6
7
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 of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement was not met evidenced by:
1
2
3
4
5
6
7
Administrator shall submit a written plan of correction that states what was done. Submit proof of staff training regarding the regulation, and staff conduct.

POC is due tomorrow.
8
9
10
11
12
13
14
Based on interviews conducted the findings indicate that former live-in staff (S5) allowed boyfriend to sleep at the facility. Staff (S5) and boyfriend were heard having sex and arguing on multiple times; which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type A
01/14/2023
Section Cited
CCR
87355(e)(2)
1
2
3
4
5
6
7
Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c).
1
2
3
4
5
6
7
Administrator shall submit proof that staff (S4) has been associated via Guardian database. In addition, a written plan shall be submitted that states what was done regarding staff visitors sleeping in the premises. Submit proof of staff training.
8
9
10
11
12
13
14
Based on record review and interviews conducted staff (S4) began working at the facility in late Dec. 2022, and as of today has not been associated to the facility. In addition, former staff (S5's) boyfriend was residing at the facility without criminal record clearance; which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230104092941
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NEWCOMB GUEST MANOR
FACILITY NUMBER: 198603461
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited
CCR
87307(a)(2)(A)
1
2
3
4
5
6
7
Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations .... (2) Resident bedrooms shall ... (A) Bedrooms shall be large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture specified below, and any resident assistant devices such as wheelchairs or walkers.
1
2
3
4
5
6
7
Administrator shall submit a written plan of correction of how this was corrected. Submit picture proof evidence by POC due date.
8
9
10
11
12
13
14
Based on observation, three (3) out of four (4) resident bedrooms had doorways that were narrow in size. Assist devices could not safely exit the room door if there was a door. This poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
02/10/2023
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not evidenced by:
1
2
3
4
5
6
7
Administrator shall submit picture proof corrections made and a written statement of what was done to correct the deficiency.
8
9
10
11
12
13
14
Based on observation, flooring trim transitions were observed througout the facility, as well as, raised concrete pavers in the backyard that contained nails that were sticking out. The north side yard door exit had a lock that required a key; which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5