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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603633
Report Date: 08/06/2024
Date Signed: 08/06/2024 05:06:47 PM

Unsubstantiated


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
08/01/2024 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240801110704
FACILITY NAME:ALONDRA GUEST MANOR INCFACILITY NUMBER:
198603633
ADMINISTRATOR:KAYA, IWONAFACILITY TYPE:
740
ADDRESS:15203 ALONDRA BLVDTELEPHONE:
(714) 228-1098
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 5DATE:
08/06/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Sandy Lin - CaregiverTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff left residents unattended.
Staff are mismanaging residents medication.
Staff did not keep a comfortable temperature for the residents in care.
Staff are not providing adequate food service to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Sandy Lin (caregiver) who allowed enterance to the facility, shortly after Administrator Iwona Kaya arrived to assist, the reason for the visit was explained.

The investigation consisted of the following: LPA interviewed the 3 Staff (S1-S3), 4 Residents (R1-R4) and 1 Family Member of a resident that was visiting during investigation. LPA obtained copies of Resident and Staff Rosters, toured all resident rooms and tested each residents air conditioners in each room, checked facility theromostate to confirm temperature was within regulation, reviewed 5 residents medications, and checked food supply.

(Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
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 6
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
08/01/2024 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240801110704

FACILITY NAME:ALONDRA GUEST MANOR INCFACILITY NUMBER:
198603633
ADMINISTRATOR:KAYA, IWONAFACILITY TYPE:
740
ADDRESS:15203 ALONDRA BLVDTELEPHONE:
(714) 228-1098
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 5DATE:
08/06/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Sandy Lin - CaregiverTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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3
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9
Staff are not safeguarding resident's personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Sandy Lin (caregiver) who allowed enterance to the facility, shortly after Administrator Iwona Kaya arrived to assist, the reason for the visit was explained.

The investigation consisted of the following: LPA interviewed 3 Staff (S1-S3), 4 Residents (R1-R4) and 1 Family Member of a resident that was visiting during investigation. LPA obtained copies of Resident and Staff Rosters, toured all resident rooms and tested each residents air conditioners in each room, checked facility theromostate to confirm temperature was within regulation, reviewed 5 residents medications, and checked food supply.

(Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20240801110704
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: ALONDRA GUEST MANOR INC
FACILITY NUMBER: 198603633
VISIT DATE: 08/06/2024
NARRATIVE
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The investigation revealed the following:
Allegation: Staff are not safeguarding resident's personal belongings.
It is alleged that food items that were purchased for R1 are being eaten by staff or being consumed by people other than R1. LPA interviewed 3 staff and 2 out of 3 staff confirmed the above allegation and stated that a previous staff who is no longer employed at the facility (as of last week), would take food that was purchased by residents visitors and instead of giving the food solely to the intended person they would cut the food in half and giving one portion to the intended resident and the other half to another resident. LPA interviewed 4 residents and 2 out of 4 residents confirmed the above allegation and stated that their belongings have either gone missing or have been given to other residents. R1 stated that they do tend to share their snacks and food with others, however, on a few occasions food that was brought for them have gone missing.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED.

California Code of Regulations, Title 22, Division 6 and Chapter 1 is being cited on the attached LIC 9099D.

Exit interview held, a copy of this report and appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20240801110704
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: ALONDRA GUEST MANOR INC
FACILITY NUMBER: 198603633
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2024
Section Cited
CCR
80026(b)
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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (b) If such a client is accepted for or maintained in care, his/her cash resources, personal property, and valuables not handled by a person outside the facility who has been designated by the client or his/her authorized representative shall be handled by the licensee or facility staff, and shall be safeguarded in accordance with the requirements specified in (c) through (n) below.
This standard was not met as evidence by:
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Administrator/Licensee to hold an in house training for all staff to be retrained in proper safeguading personal belongings of residents, which includes all belongings including food that is either purchaed with residents own funds or gifted to them. A copy of the training materials and training log with participants is to be provided to LPA via email by POC due date. tena.herrera@dss.ca.gov
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Interviews with 3 staff 2 out of the 3 staff confirmed that a previous staff would (knowingly) take food inteneded for one resident and divide it to share with other residents without their permission. Interviews with 2 residents also confirmed this to be true.
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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: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20240801110704
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: ALONDRA GUEST MANOR INC
FACILITY NUMBER: 198603633
VISIT DATE: 08/06/2024
NARRATIVE
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The investigation revealed the following:
Allegation: Staff left residents unattended.
It is alleged that at approximately 1:30-2:30pm on Thursday August 1, 2024, S2 was observed to be sleeping during there shift and left residents unattended. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation. It was revealed during interviews that there are currently 3 live-in staff at the facility (one who is in training) and during the disclosed time is the time that staff take their staggered lunch breaks and residents were not left unattended as S3 was in the kitchen cleaning up after residents lunch hour. LPA interviewed 4 residents 3 out of 4 residents denied the allegation and stated they have not been left unattended at the facility and receive assistance promptly when needed. LPA interviewed 1 of the residents family members that was visiting during the investigation and they stated that they have never observed staff sleeping during their shifts and have never experienced staff leaving the residents unattended.
Allegation: Staff are mismanaging residents medication.
It is alleged that staff administered R1 the incorrect medication. LPA reviewed 5 residents medication with no issues observed, all medication was properly labeled and in their original containers. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation and stated they are very careful when it comes to medication and have not made a mistake while administering medication. LPA interviewed 4 residents and 4 out of 4 denied the above allegation. Interview with R1, they stated that they are very much aware of the medication they take and what it looks like and have never been given the incorrect medication. LPA interviewed 1 of the residents family members that was visiting during the investigation and they stated that they have been present during medication administration and have never observed any issues.
Allegation: Staff did not keep a comfortable temperature for the residents in care.
It is alleged that the temperature in the facility is left at an uncomfortable temperature, reaching between 85-90 degrees F, and that the air conditioner is broken. LPA toured facility and observed thermostat in front living room to be at 85 degrees F (which is within the required rage of 68-85 degrees F). LPA observed fans in common areas to be operable. LPA toured each resident room and observed portable air conditioners in each room that were operable. Each resident room was also observed to be at a comfortable temperature. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation and stated that all residents air conditioners have been operable and the facility is maintained at a comfortable temperature at all times. LPA interviewed 4 residents and 4 out of 4 residents denied the above allegation.
(Continued on LIC9099-C)
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20240801110704
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: ALONDRA GUEST MANOR INC
FACILITY NUMBER: 198603633
VISIT DATE: 08/06/2024
NARRATIVE
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Allegation: Staff are not providing adequate food service to residents.
It is alleged that the facility does not provide residents with nutritious food and that the food is horrible. LPA toured kitchen and there was sufficient supply of perishable and non-perishable foods. LPA observed there to be fruits, vegetables, and a selection of different meats. Facility has a pantry and surplus of food in garage refrigerator. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation and stated that the facility maintains a sufficient about of food at all times with multiple items to choose from, as different residents have different preferences. LPA interviewed 4 residents and 4 out of 4 residents denied the above allegation and stated the food is good and staff are accommodating to their preferences. LPA interviewed 1 of the residents family members that was visiting during the investigation and they stated that their relative is well fed at the facility and the food is of good quality.

Based on statements and interviews conducted with staff and residents, review of medications, review of food supply and LPA's observations during tour of facility, there was not enough supportive evidence to concur with the reported allegations.
Although the allegations may have happened 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: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6