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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603461
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:56:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
07/15/2024 and conducted by Evaluator Erik Zaragoza
COMPLAINT CONTROL NUMBER: 28-AS-20240715094833
FACILITY NAME:NEWCOMB GUEST MANORFACILITY NUMBER:
198603461
ADMINISTRATOR:KAYA, IWONAFACILITY TYPE:
740
ADDRESS:10647 NEWCOMB AVETELEPHONE:
(562) 902-1943
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:6CENSUS: 6DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:TJ Navallo - Caregiver TIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Facility does not have a sufficient food supply
Staff would not allow resident to have a visitor
Facility staff restricting resident's telephone access
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced initial complaint visit to investigate the allegations listed above. LPA met with TJ Navallo, caregiver for the facility, and was granted entrance into the facility.

The investigation consisted of the following: LPA obtained the facility staff and resident rosters, examined the food supply for the facility, obtained the FACE Sheets for Residents #1 - 6 (R1 - R6), obtained the admission agreement for R1, and interviewed R1 - R6, Staff #1 - 3 (S1 - S3), and Witness #1 (W1) as well.

The investigation revealed the following: In regards to the allegation that "Facility does not have a sufficient food supply," it was alleged that the facility's refridgerator was bare when it was checked.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
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 7
Control Number 28-AS-20240715094833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NEWCOMB GUEST MANOR
FACILITY NUMBER: 198603461
VISIT DATE: 07/16/2024
NARRATIVE
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During interviews with the residents, one (1) out of six (6) residents interviewed corroborated the allegation that at times the facility does not have enough food. One of the residents interviewed stated that the food supply is "up and down" at times. Another resident interviewed stated that they get enough food and haven't been aware of the facility being out of food in the past. During interviews with the staff, zero (0) out of three (3) interviewed stated that they do not have a sufficient food supply. One of the staff interviewed stated that they make sure that every resident gets food when they request for it. Another staff interviewed stated that residents get three (3) meals per day along with snacks, and that grocery shopping is done every week. Upon checking the facility's perishable food supply, LPA determined the required 2-day supply was not met for the six (6) residents living in the facility.

In regards to the allegation that "Staff would not allow resident to have a visitor," it is alleged that family members of R1 have not been allowed to visit R1 since 7/3/2024 due to R1's Power of Attorney (POA) request that they do not visit R1 due to safety concerns. During interviews with the Residents, one (1) out of six (6) residents interviewed did not corroborate the allegation. R1 explained during the interview that they would actually like their family that was prevented from visiting them on 7/15/2024 to visit them. None of the other residents interviewed stated that they are prevented from receiving visitors at the home. During interviews with the staff, none of them corroborated that they are improperly restricting the visitation rights of residents. One staff member interviewed stated that R1 has been financially abused and neglected by the family members in the past, and that is why R1's POA has requested that the other family members of R1 do not visit them at the facility. During record review of R1's POA document LPA did not observe anything in writing indicating that POA can restrict R1's visitation rights. LPA was not provided any legal documentation indicating that R1's visitation rights can be restricted by the facility staff.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20240715094833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NEWCOMB GUEST MANOR
FACILITY NUMBER: 198603461
VISIT DATE: 07/16/2024
NARRATIVE
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In regards to the allegation "Facility staff restricting resident's telephone access," it is alleged that the facility staff are not picking up calls from R1's family who have been attempting to contact R1. During interviews with the residents, one (1) out of six (6) residents interviewed indicated that they do not have access to speak with their family through the facility's phone. During an interview with R1 they stated that they have not been allowed to speak with their family members by phone, and they are not aware of the reason why they haven't been allowed to speak with their family. Another resident interviewed stated that sometimes there will be an individual using the phone so it is not immediately available, however it is typically always available. During interviews with the staff, two (2) out of three (3) corroborated that phone calls were restricted for R1's family. One staff interviewed stated that have been advised not to answer the phone whenever the family of R1 calls, and that R1's family calls from various phone numbers. Another staff interviewed was told that R1's POA has a preference that the facility staff do not accept calls from R1's other family members due to the potential for abuse, and therefore they have not been taking R1's family's calls, nor have they been notifying R1 that they are received calls from R1's family.

Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC9099Ds.

Exit interview held and a copy of the report and appeal rights was provided to the administrator Iwona Kaya.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20240715094833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
07/30/2024
Section Cited
CCR
87555(b)(26)
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(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
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Administrator is to ensure that the food supply requirement is met at the facility at all times. Administrator is to increase the facility's perishable food supply and submit proof to LPA that it has been restocked by the POC due date.
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Based on interview and observation, LPA determined that there was not a sufficent 2-day supply of perishable foods within the facility for residents, which poses a potential health and safety risk for residents in care.
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Type B
07/30/2024
Section Cited
CCR
87468.1(a)(11)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors (...) permitted to visit privately during reasonable hours (...) provided that the rights of other residents are not infringed upon.
This regulation is not met as evidenced by:
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Administrator is to ensure that all residents are allowed visitors at all times if the resident agrees they wish to see the visitors. Administrator is to submit a written plan on how the facility will mee the requirement going forward by the POC due date.
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Based on interviews conducted, LPA determined that R1 has been denied visitation from his family members during his stay at the facility, which poses a potential health and safety risk to residents 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20240715094833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2024
Section Cited
CCR
87468.2(a)(1)
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(1) To have (...) telephone conversations (...) and meetings of resident and family groups.
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Administrator is to ensure that all residents are allowed to speak with their family members when they call the facility number. Administrator is to submit to LPA the facility's plan on how they will meet the regulation by the POC due date.
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This regulation is not met as evidenced by:
Based on interviews, LPA determined that the resident had not been allowed to speak with their family members on the phone when they called the facility, which poses a potential health and safety risk to residents 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
07/15/2024 and conducted by Evaluator Erik Zaragoza
COMPLAINT CONTROL NUMBER: 28-AS-20240715094833

FACILITY NAME:NEWCOMB GUEST MANORFACILITY NUMBER:
198603461
ADMINISTRATOR:KAYA, IWONAFACILITY TYPE:
740
ADDRESS:10647 NEWCOMB AVETELEPHONE:
(562) 902-1943
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:6CENSUS: 6DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:TJ Navallo - Caregiver TIME COMPLETED:
05:10 PM
ALLEGATION(S):
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2
3
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Staff left resident in bathroom unassisted
INVESTIGATION FINDINGS:
1
2
3
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5
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13
Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced initial complaint visit to investigate the allegations listed above. LPA met with TJ Navallo, caregiver for the facility, and was granted entrance into the facility.

The investigation consisted of the following: LPA obtained the facility staff and resident rosters, examined the food supply for the facility, obtained the FACE Sheets for Residents #1 - 6 (R1 - R6), obtained the admission agreement for R1, and interviewed R1 - R6, Staff #1 - 3 (S1 - S3), and Witness #1 (W1) as well.

The investigation revealed the following: In regards to the allegation that "Staff left resident in bathroom unassisted," it was alleged that the facility staff left R1 in the bathroom unassisted without toilet paper and did not help him when he was calling for help.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20240715094833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NEWCOMB GUEST MANOR
FACILITY NUMBER: 198603461
VISIT DATE: 07/16/2024
NARRATIVE
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During interviews with the residents, zero (0) out of six (6) interviewed stated that staff have left them in the bathroom unassisted. During an interview with R1, they stated that they receive assistance with their toileting needs from the staff, and they have never left them in the bathroom when they required assistance. Another resident interviewed stated that they get assistance with their incontinence care from the staff at the facility. Other residents interviewed stated they do not require assistance with their toileting needs. During interviews with staff, zero (0) out of three (3) interviewed did not corroborate the allegation. One staff interviewed stated that they assist R1 with wiping personally by using specialized wipes that they keep in the resident rooms, and when R1 claims they are done toileting they call for this staff member, and the staff always assists in cleaning the resident afterwards. LPA observed the supply of wipes that were kept in the resident's room.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7