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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603461
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:07:58 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
PUBLIC
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: 5DATE:
09/10/2024
UNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:TJ Navallo - CaregiverTIME COMPLETED:
04:23 PM
ALLEGATION(S):
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Staff do not provide enough food for residents in care
INVESTIGATION FINDINGS:
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***This report supersedes report dated on 7/16/2024. The reason the report is being superseded is because the deficiency type needs to be updated to a "Type A" violation rather than a "Type B" violation. Additionally, the Plan of Correction (POC) due date needs to be updated as well. All other findings will remain the same.***

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.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
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 3
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: 09/10/2024
NARRATIVE
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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 refrigerator was bare when it was checked. 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 two (2) day supply was not met for the six (6) residents living in the facility.

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 is being cited on the attached LIC9099D.

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: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2024
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 maintained on the premises 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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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: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3