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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603798
Report Date: 07/29/2025
Date Signed: 07/29/2025 01:54:50 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
07/23/2025 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250723090756
FACILITY NAME:EVELYN'S MANORFACILITY NUMBER:
198603798
ADMINISTRATOR:HALLMAN, KAYLONFACILITY TYPE:
740
ADDRESS:1126 E 82ND STREETTELEPHONE:
(310) 739-9303
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY:6CENSUS: 3DATE:
07/29/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Kaylon Hallman - AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff did not ensure medications were dispensed and prescribed to resident in care.
Staff did not inventory residents medications upon entry to the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegations. LPA met with Kaylon Hallman, Administrator and explained the purpose of the visit.

The investigation consisted of the following: LPA obtained copies of the staff & resident rosters, training logs for S1-S2's medication training, and Resident #1 (R1) pertinent files such as: Identification/Emergency Information and Kaiser Medical assessment. Administrator cannot provide copies of any other files for R1 and no incident reports submitted. LPA interviewed Staff #1 (S1) - Staff #2 (S2) and Resident #2 (R2). Residence #1 (R1) has moved out and in the hospital, therefore not interviewed. LPA attempted to interview Resident #3 (R3) - Resident #4 (R4), but unsuccessful due to their cognitive abilities. *****CONTINUED ON LIC9099-C*****

Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
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-20250723090756
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: EVELYN'S MANOR
FACILITY NUMBER: 198603798
VISIT DATE: 07/29/2025
NARRATIVE
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The investigation revealed the following:

In regards to the allegation: “Staff did not ensure medications were dispensed and prescribed to resident in care.” It is alleged that upon the resident’s temporary placement in the facility on 6/26/2025, staff missed giving a resident their medication for a full day and failed to ensure that the resident received it. Interview with S1 revealed that medication for R1 was not administered as per the doctors’ orders because S1 failed to properly assess R1 prior to R1's transfer to the facility. Additionally, the paramedics who brought R1 into the facility did not give S1 any documents for R1, nor did they inform him about any medications R1 was taking. Due to this, S1 did not have a record of R1's current prescribed medications. S2 stated that she has not administered medications to any of the (3) current residents in the facility. Interview with R2 revealed that they do not take medications. LPA unsuccessfully interviewed R1 as they moved out of the facility on 6/27/2025 and is now in the hospital. LPA confirmed that an incident/injury report (SIR) was not submitted for this incident. The lack of documentation and interviews conducted corroborate this allegation.

In regards to the allegation: “Staff did not inventory residents medications upon entry to the facility.” It is alleged that upon the resident’s temporary placement in the facility on 6/26/2025, the resident’s medication was left in the bag on the floor of the room and staff never checked the bag to check their medications. Interview with S1 revealed that the paramedics brought R1 to the facility on the evening of June 26, 2025. S1 stated that the paramedics did not give S1 any documents for R1, nor did they inform him about any medications R1 was taking. S1 indicated that R1 came in with bags of dirty clothes and inside the bag were R1's medications. However, S1 also stated that paramedics advised S1 to be cautious when handling R1 because of R1's medical condition that might be contagious while taking antibiotics. For this reason, S1 did not take an inventory of R1's belongings. Interview with R2 revealed that they could not recall whether their personal items were inventoried by the staff when they moved. LPA unsuccessfully interviewed R1 as they moved out of the facility on 6/27/2025 and is now in the hospital. LPA confirmed that an incident/injury report (SIR) was not submitted for this incident. The lack of documentation and interviews conducted corroborate this allegation.

Based on LPA’s interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Administrator, Kaylon Hallman along with the Appeals Rights.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250723090756
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: EVELYN'S MANOR
FACILITY NUMBER: 198603798
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2025
Section Cited
CCR
87458)a)(3)
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87458 Medical Assessment ..(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment...in the resident's record.(3) A record of current prescribed medications....
This requirement is not met as evidenced by:


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Administrator agreed to develop an outline of a written plan to ensure the requirements of this regulation are met and self certify that he read, reviewed and understood Title 22 Regs. 87458 and submit plan/certification to CCL/LPA by POC due date.
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Based on interviews, records review, the licensee did not comply with the section cited above in which Administrator failed to assess R1 and did not obtain documentation of a medical assessment prior to accepting R1 as a resident which poses a potential health, safety or personal rights risk to residents in care.
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Type B
07/29/2025
Section Cited
CCR
87465(a)(6)
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87465 ..Incidental Medical and Dental Care..(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical..and provide for assistance in obtaining such care...(6) When requested by the Department, a record of dosages of medications...shall be maintained...
This requirement is not met as evidenced by:


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Administrator agreed to develop a written plan for maintaining medication records and record keeping practices upon admission of residents. Administrator to self certify that he read, reviewed and understood Title 22 Regulation 87465 and submit plan/certification to CCL/LPA by POC due date.
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Based on interviews, records review, the licensee did not comply with the section cited above in which Administrator failed to inventory medications and maintain these required records. which poses a potential health, safety or personal rights 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: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3