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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603461
Report Date: 11/02/2023
Date Signed: 11/02/2023 01:47:31 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 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
12/27/2022 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221227120626
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:
11/02/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Iwona Kaya TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has failed to provide resident's medical records
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jose Villalobos made an unannounced initial complaint visit in response to the above mentioned allegation. LPA Villalobos met with Administrator Iwona Kaya and the purpose of the visit was discussed.

Iniital visit conducted on 1/5/23 and consisted of the following: LPA interviewed Administrator telephonically (S1) and toured the physical plant. LPA requested the following documents from Resident #1's (R1s) file: Facehseet, Physicians Report, Medication Records Log for the last month, Needs and Services Plan, Appraisal Sheet.

As of todays visit, LPA interviewed Residents #2-#5 (R2-R5), Staff #2-#3 (S2-S3) and R1's responsible party. R1 is no longer in the facility and was unavailable for interview. The investigation revealed the following:

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
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 2
Control Number 28-AS-20221227120626
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: 11/02/2023
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
In regards to the allegation "Facility has failed to provide resident's medical records" it was alleged that R1's medical records were requested by an authorized representative and the facility did not provide them. (3) of (3) Staff interviewed denied the allegation. (4) of (4) Residents interviewed could not corroborate the allegation. Interviews state that R1's responsible party had hired a law firm to collect medical records for R1. The medical records for R1 were requested on 12/21/22 by the firm. Once the facility verified the request, a copy of R1's file was provided via verified mail on 12/24/22. Interviews with S1 and R1's responsible party state that the medical records were meant to have been requested from a different facility where R1 had resided in the past and not from this facility. The facility would not have the medical records, that were being requested by the firm, that were from a time prior to R1 being admitted into the facility. R1's responsible party confirmed these details and did not have issue with the facility. Based on interviews, observations, and file review there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are 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 a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2