198603461-5-24-2024-28-AS-FFIS-D5ZM8J-20240607092309

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603461
Report Date: 05/24/2024
Date Signed: 05/24/2024 01:33:12 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
05/21/2024 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20240521111539

FACILITY NAME:	NEWCOMB GUEST MANOR		FACILITY NUMBER:	198603461
ADMINISTRATOR:	KAYA, IWONA		FACILITY TYPE:	740
ADDRESS:	10647 NEWCOMB AVE		TELEPHONE:	(562) 902-1943
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	6	CENSUS: 3	DATE:	05/24/2024
		UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Iwona Kaya, administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Administrator did not provide a refund to resident's responsible party.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility and met Iwona Kaya, administrator. The purpose of today’s visit and the allegation were discussed.

The investigation consisted of residents/ staff interviews, facility tours, and review of facility records. LPA obtained resident/staff roster and residents’ facility files.

The investigation revealed the following:

In regards of Administrator did not provide a refund to resident's responsible party, it was alleged that administrator failed to refund the remaining balance from the resident’s account to the responsible party after moved out. LPA attempted but failed to interview resident#1 (R1). Per resident interviews, from resident#2 to resident #4, all three (3) residents could not corroborate the allegation. Resident interviews revealed that residents had never requested a refund since residing at the facility. (-continued in LIC 9099C-)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240521111539

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: 05/24/2024

NARRATIVE

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Per staff interview, from staff#1 to staff#3, all three (3) staff interviewed denied the allegation. Staff interviews revealed that administrator would handle the refund. Per administrator interview, the 2nd refund check was mailed out to the responsible party two days ago. Per record review, the balance was fully refunded. Therefore, administrator had refunded the resident's remaining balance to the responsible party.

Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above.

Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted with administrator and the finding was discussed. A copy this report was provided at time of the visit.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

LIC9099 (FAS) - (06/04)

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